Medical Nutrition Therapy for HIV/AIDS

Anggun Rindang Cempaka, S.Gz, MS, RD.

PS S1 Ilmu Gizi Fakultas Ilmu Kesehatan Universitas Brawijaya
Outlines

01 Overview of HIV/AIDS
02 How HIV affect nutritional status
03 Nutritional assessment
04 Nutrition intervention
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Key Terms
AIDS
(Acquired Immune Deficiency Syndrome)
The late stage of HIV infection that occurs
when the body’s immune system is badly
damaged because of the virus.

HIV → AIDS when:

▪ The number of their CD4 cells falls below
200 cells/mm3 blood; OR

▪ They develop one or more opportunistic

infections regardless of their CD4 count
Overview
▪ HIV targets the immune system and weakens HIV
people's defence systems against infections and
some types of cancer
▪ Virus destroys and impairs the function of
immune cells
▪ Infected individuals gradually become immuno-
deficient (measured by CD4 cell count)
▪ Increased susceptibility to a wide range of
infections, cancers and other diseases
(WHO, 2019)
Etiology of HIV
▪ Having unprotected anal or vaginal sex.
▪ Contact with certain bodily fluids of a person with HIV, most commonly
during unprotected sex (sex without a condom or HIV medicine to
prevent or treat HIV).
▪ Sharing injection drug equipment.
▪ Mother-to-child transmission during delivery or breastfeeding.
▪ Blood transfusion.

(hiv.gov; Fenton and silverman, 2008; WHO, 2019)

 Pathophysiology of HIV

HIV invades the genetic core of the CD4+ cells, which For people living with
HIV (PLHIV)
are T-helper lymphocyte cells, and which are the
principal agents involved in protection against infection. Poor nutrition worsens
the effects of HIV by
further weakening the
immune system. This
may lead to a more
HIV infection causes a progressive depletion of CD4+
rapid progression of
cells, which eventually leads to immunodeficiency. the disease

(Mahan and Raymond. Krause's Food & the Nutrition Care Process, 14 th Ed; 2017)
How HIV affects Nutritional Status
Important points:
▪ Decrese food intake
▪ Decrease nutrients
absorption
▪ Increase energy
requirements

(WHO, 2009)
Nutritional Assessments
 HIV Classifications - WHO

Clinical Stage 1 Clinical Stage 2

▪ Asimptomatis ▪ BB menurun <10% dari BB semula
▪ Pembesaran kelenjar getah ▪ Kelainan kulit dan mukosa ringan
bening (dermatitis, infeksi jamur kuku)
▪ Skala aktivitas: asimptomatis, ▪ Infeksi saluran napas bagian atas
aktivitas normal ▪ Skala aktivitas: simptomatis, aktivitas
normal
 HIV Classifications - WHO
Clinical Stage 3
▪ BB menurun >10% dari BB
semula
▪ Diare kronis berulang, demam
tanpa sebab >1 bulan
▪ Kandidiasis oral, TB paru
▪ Skala aktivitas: selama 1 bulan
terakhir di tempat tidur <50%
Clinical Stage 4
▪ Wasting syndrome (BB turun 10% + diare
kronis >1 bulan atau demam >1 bulan)
▪ Pneumocystis carinii pneumonia (PCP)
▪ Toxoplasmosis pada otak, herpes simplex
virus
▪ Aktivitas sangat tergantung pada orang
lain
 HIV Classifications - CDC
Clinical Stage A
CD4+ >500 sel/ml
▪ Meliputi infeksi HIV tanpa gejala (asimptomatik),
▪ Limfadenopati generalisata yang menetap,
▪ Infeksi HIV akut primer dengan penyakit penyerta atau adanya riwayat
infeksi HIV akut.
 HIV Classifications - CDC
Clinical Stage B
CD4+ 200 – 499 sel/ml
Terdiri atas kondisi dengan gejala (simptomatik) pada orang yang terinfeksi HIV yang
tidak termasuk dalam kategori C dan memenuhi paling sedikit satu dari kriteria berikut:
▪ Keadaan yang dihubungkan dengan infeksi HIV atau
▪ Adanya kerusakan kekebalan dengan perantara sel (cell mediated immunity), atau
▪ Kondisi yang dianggap oleh dokter telah memerlukan penanganan klinis atau
membutuhkan penatalaksanaan akibat komplikasi infeksi HIV.

Termasuk kedalam kategori ini yaitu angiomatosis basilari, kandidiasis orofaringeal, kandidiasis
vulvovaginal, dysplasia leher rahim, herpes zoster, neuropati perifer, penyakit radang panggul.
 HIV Classifications - CDC
Clinical Stage C
CD4+ < 200 sel/ml
Meliputi gejala yang ditemukan pada pasien AIDS dan pada tahap ini orang yang
terinfeksi HIV menunjukkan perkembangan infeksi dan keganasan yang mengan-
cam kehidupannya, meliputi:
▪ Sarkoma Kaposi, Kandidiasis bronki/trakea/paru, Kandidiasis esophagus
▪ Kanker leher rahim invasif, Coccidiodomycosis, Herpes simpleks
▪ Cryptosporidiosis, Retinitis virus sitomegalo, Ensefalopati yang berhubungan dengan
HIV, Bronkitis/Esofagitis atau Pneumonia, Limfoma Burkitt, Limfoma imunoblastik dan
Limfoma primer di otak, Pneumonia Pneumocystis carinii.
Nutrition Goals

01 Improve patient’s nutritional status

02 Prevent further functional damage because

of malnutrition
03 Improve patient’s tolerance to antiretroviral
drugs

04 Improve GIT disorder because of HIV infection

(nausea, diarrhea, bloating)

05 Increase patient’s quality of life

(ESPEN, 2006)
Nutrition Intervention
Energy Requirements
Adult & Adolescents
▪ During the asymptomatic phase,
energy requirements increase by
10%
▪ During the symptomatic phase,
energy requirements increase by
20 to 30%
(WHO, 2003: USAID, 2007; Kosmiski, 2011)
Energy Requirements
Children
▪ During the asymptomatic phase, energy
requirements increase by 10 percent.
▪ During the symptomatic phase with no
weight loss, energy requirements increase
by 20 to 30 percent.
▪ During the symptomatic phase with
weight loss, energy requirements increase
by 50 to 100 percent.
(WHO, 2003: USAID, 2007)
 Nutrition Intervention
Protein Requirements
▪ There are insufficient data at present to support an increase in protein intake for
PLWHA above normal requirements for health i.e. 12% to 15% of total energy in-
take (WHO, 2003)
▪ Protein requirement may be estimated at 1 – 1.4 g/kg for maintenance and 1.5 –
2 g/kg for repletion. Because of the increased protein requirements, protein res-
triction is indicated only in persons with severe hepatic or renal disease (Fenton and
Silverman, 2008)

▪ The target for protein intake should be 1.2 g/kg bw/day in stable phases of the
disease while it may be increased to 1.5 g/kg bw/day during acute illness (ESPEN,
2006)
 Nutrition Intervention
Fat Requirements
▪ Fat recommendation for PLWHA with dyslipidemia is not different from normal
patients (without HIV)
▪ NCEP ATP III recommendation:
▪ Total fat: 25 – 35% of total energy
▪ SFA: maximal 7% of total energy
▪ Cholesterol: <200 mg/day; Plant sterol: 2 gram/day
▪ Dietary fiber: 10 – 25 gram/day
▪ PLWHA who has fat malabsorption or diarrhea should take low fat diet (MCT)
▪ Omega 3 is recommended to support immune system (Asuhan Gizi Klinik, 2019)
 Nutrition Intervention
Fluids and Electrolytes Requirements
▪ Fluids in HIV infected individual are similar to those of healthy
individuals and are calculated to be 30 – 35 ml/kg/day with
additional amounts to compensate for losses from diarrhea, nausea
and vomiting, night sweats, and prolonged fever.
▪ Replacement of electrolyte losses (sodium, potassium, and chloride)
in the presence of vomiting and diarrhea is also recommended.

(Fenton and Silverman, 2008)

Nutrition Intervention
Micronutrients Requirement
HIV-infected adults HIV-infected children WHO recommends daily
and children should (6-59-month-old) who iron-folate supplementa-
consume diets that living in resource-limited tion (400 µg of folate
ensure settings should receive and 60 mg of iron) during
micronutrient periodic (every 4-6 months) six months of pregnancy
intakes at RDA Vit A supplements (100.000 to prevent anemia, and
Levels → especially IU for infants 6 to 12 twice-daily supplements
Vit A, B12, zinc months and 200.000 IU for to treat severe anemia.
(deficiency) children >12 months).
(WHO, 2003)
Nutrition Intervention

(ESPEN, 2006)
Nutrition Intervention
ONS or EN can be given
to PLWHIV who has:
1. Low intake level (intake
<1000 kcal/day)
2. Dysfagia; nutrient mal-
digestion/malabsorp-
tion
3. Low compliance to ARV
treatment
4. Opprtunistic infection
or tumour

(ESPEN, 2006; Asuhan Gizi Klinik, 2019)

 Optimal nutrition is an important adjunct in
the clinical care of patients with HIV.
Nutritional interventions may improve the
quality and span of life and symptom
management, support the effectiveness of
medications, and improve the patient’s
resistance to infections and other disease
Nutrition complications by altering immunity

and HIV (Somarriba et al., 2010. The effect of aging, nutrition, and exercise during HIV infection.
HIV/AIDS - Research and Palliative Care 2010:2 191–201)
 A cross-sectional study of men with
advanced, asymptomatic HIV
demonstrated a positive association
between protein intake and body cell
mass independent of muscle-building
Nutrition activity

and HIV (Williams SB, Bartsch G, Muurahainen N, Collins G, Raghavan SS, Wheeler D. Protein
intake is positively associated with body cell mass in weight-stable HIV-infected men.
J Nutr. 2003; 133:1143–1146)
 Clark et al. reported that supplementation
with specific nutritional supplements,
including an amino acid mixture of arginine,
glutamine, and β-hydroxy-β-methylbutyrate
can significantly increased body weight and
decreased viral load but did not alter energy
Nutrition and protein intake, fat mass, or CD4+ count

and HIV (Clark RH, Feleke G, Din M, et al. Nutritional treatment for acquired immunodeficiency virus-
associated wasting using beta-hydroxy beta-methylbutyrate, glutamine, and arginine: a randomized,
double-blind, placebo-controlled study. JPEN J Parenter Enteral Nutr. 2000; 24:133–139)
How to deal with Anorexia
▪ Memberi makanan padat energi, TETP
▪ Berikan makanan yang disukai
▪ Hindari minum sebelum makan
▪ Makan merupakan bagian dari pengobatan
▪ Porsi kecil dan sering
▪ Menghindari bau yang menyengat
▪ Memberikan makanan dengan warna dan bentuk yang menarik
▪ Menciptakan suasana makan yang menyenangkan
How to reduce Nausea/Vomiting

▪ Mengkonsumsi 6-8 porsi kecil makanan

▪ Mengkonsumsi cairan yang dapat mengurangi mual/muntah
(teh jahe atau minuman lemon) secara teratur untuk
mencegah dehidrasi
▪ Pilih makanan kering yang tidak berbau
▪ Berikan makanan lunak dan rendah lemak
▪ Hindari makanan terlalu manis
▪ Tidak tiduran setelah makan
How to overcome Diarrhea

▪ Banyak minum
▪ Makan porsi kecil dan sering
▪ Hindari makan terlalu manis dan berlemak
▪ Menghindari susu fullcream selama diare
▪ Beri makanan sumber serat larut air
▪ Menghindari makanan yang bergas
References
Fenton, M & Silverman, EC. 2008. Medical nutrition therapy for HIV disease.
In Mahan, LK & Escott Stump, S. Krause’s Food and Nutrition Therapy.
Canada; Saunders Elsevier.
Kosmiski, L . Energy expenditure in HIV infection. Am J Clin Nutr 2011; 94 (suppl):
1677S–82S.
Mahan and Raymond. 2017. Medical nutrition therapy for HIV and AIDS. Krause's
Food & the Nutrition Care Process, 14th Ed.
Ockenga J, et al. 2006. ESPEN Guidelines on Enteral Nutrition: Wasting in HIV and
other chronic infectious diseases. Clinical Nutrition. 25, 319–329.
WHO. 2003. Nutrient requirements for people living with HIV/AIDS.
WHO. 2009. Nutrition Care and Support for People Living with HIV.
WHO. 2019. HIV/AIDS.
Thank you
Any Questions?