CHAPTER ONE

1 INTRODUCTION

1.1 Background of Study

The AIDS epidemic is one of the most destructive health crises of modern times ravaging

families and communities around the world. By the end of 2008, UNAIDS/WHO estimated that

globally, a total of 33.4 million people were living with HIV, where by 31.3 million were adults.

In sub-Saharan Africa, 22.4 million people were living with HIV in 2008 (UNAIDS, 2009).

Although efforts have been put in place to fight HIV/AIDS in Nigeria, about 1million people are

leaving with HIV/AIDS (MOH and ORC Macro, 2006).

According to Nigeria HIV/AIDS serobehavioural survey (2004-2005), the prevalence of

HIV among adults (18-59 years of age) was 6.7 % and the prevalence is higher in Kampala

district about 8.5 % than other districts. The high prevalence of HIV/AIDS in this most

productive age has great impact on health, economic and social aspects. HIV infection

exacerbates malnutrition through its attack on the immune system and its impact on food intake,

nutrient absorption and utilization. Malnutrition also increases fatigue, reduces physical activity

and work productivity of people living with HIV and AIDS (Piwoz and Preble, 2000). Ott et al.

(1993) noted that decrease in body weight and lean body mass (LBM) are common problems in

HIV-positive persons and depletion of body cell mass may occur early in asymptomatic HIV

positive individuals before progression to AIDS. Wasting in HIV/AIDS is usually preceded by

losses in appetite, repeated infections, weight fluctuations, and subtler changes in body

composition (Babammento and Kotler, 1997).

To understand the relationship between nutrition and HIV/AIDS, one must consider the

effect of the disease on body size and composition. Body size is most commonly expressed in

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terms of body weight and height while body composition is expressed as body cell mass (the

metabolically active, energy-exchanging tissue of the body), lean body (an estimate of protein

and mineral reserves, mainly stored in muscle) and fat mass of the body (Piwoz and Preble,

2000). In a study by Reiter (1996) it was reported that measurements of lean body mass can

predict survival independent of CD4 count. The study also showed some similarity between

weight loss in HIV and starvation. Further more, starvation caused death when people with AIDS

reached 66% of ideal body weight or 54% of ideal body cell mass.

HIV accounts for significant immunosuppression in an infected individual. If the

corroboratory indices of good health are satisfactory, the suppression of immune defences can be

mitigated. One such index is nutrition. HIV, immune expression, and nutrition interactions are

complex and related to each other. Malnutrition adds fuel to the fire by accelerating the progress

of HIV infection to AIDS. HIV/AIDS is associated with biological and social factors that affect

the individual’s ability to consume, utilize, and acquire food. Once there is an infection with

HIV, the patient’s nutritional status declines further leading to immune depletion and HIV

progression (Beisel, 1996). Good nutrition along with continued monitoring of body composition

changes and antiretroviral treatment are therefore vital for the well being of PLHIV.

1.2 Problem Statement

The high prevalence of HIV/AIDS (6.7 %) among adults aged 18-59years in Nigeria has

great implications on nutritional status of PLHIV (MOH and ORC Macro, 2006). HIV infection

increases energy requirements and affects nutrition through increasing energy expenditure,

reductions in food intake, nutrient malabsorption and loss and complex metabolic alterations

(Macallan, 1995; Babamento and Kotler, 1997). The inadequate dietary intake among PLHIV to

meet the increased demand for both energy and protein associated with HIV infection result in

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weight loss (Piwoz and Preble, 2000). Wasting in AIDS is characterized by catabolism, there is

preferential loss of lean body mass over fat and conversely or preferential gain of fat over lean

mass. This continuous loss of cell mass also promotes progression of AIDS and can hasten death

(Reiter, 1996; Wanke et al., 2002). In most HIV clinics, patients are weighed almost at every

visit however measuring weight alone can be a misleading indicator of nutritional status because

lean body mass among PLHIV is lost in preference to fat. There is no way to distinguish between

body fat (BF), lean body mass (LBM), and water when weight measurements are used alone

(Wanke et al., 2002).

Hogg et al. (1998) and Castleman et al. (2004) noted the role of antiretroviral therapy in

the management of HIV and contribution to improved nutritional status; however, they

mentioned that ART could create additional needs and dietary constraints which can contribute

to weight change. In addition, Wanke et al. (2002) noted that the improved nutritional status or

the body weight gain that is from antiretroviral treatment does not necessarily mean gaining in

lean body mass. Wanke et al. (2002) added complications of HAART such as fat maldistribution

may mask the subtle change of lean body mass (LBM). Therefore this indicates that, even though

HAART has dramatically altered the course of HIV/AIDS but questions related to the

management of patients on HAART remain unanswered.

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 CHAPTER TWO

2.1 HIV/AIDS

Human immunodeficiency virus infection and acquired immune deficiency syndrome

(HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency

virus (HIV). Following initial infection, a person may not notice any symptoms or may

experience a brief period of influenza-like illness. Typically, this is followed by a prolonged

period with no symptoms.As the infection progresses, it interferes more with the immune system,

increasing the risk of developing common infections such as tuberculosis, as well as other

opportunistic infections, and tumors that rarely affect people who have uncompromised immune

systems. These late symptoms of infection are referred to as acquired immunodeficiency

syndrome (AIDS). This stage is often also associated with unintended weight loss (Harden and

Victoria, 2012)

HIV is spread primarily by unprotected sex (including anal and oral sex), contaminated

blood transfusions, hypodermic needles, and from mother to child during pregnancy, delivery, or

breastfeeding. Some bodily fluids, such as saliva and tears, do not transmit HIV. Methods of

prevention include safe sex, needle exchange programs, treating those who are infected, pre- and

post-exposure prophylaxis, and male circumcision. Disease in a baby can often be prevented by

giving both the mother and child antiretroviral medication. There is no cure or vaccine; however,

antiretroviral treatment can slow the course of the disease and may lead to a near-normal life

expectancy. Treatment is recommended as soon as the diagnosis is made. Without treatment, the

average survival time after infection is 11 years (Harden and Victoria, 2012).

2.1.1 Signs and Symptoms

There are three main stages of HIV infection: acute infection, clinical latency, and AIDS.

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2.1.1.1 Acute Infection

Main symptoms of acute HIV infection

The initial period following the contraction of HIV is called acute HIV, primary HIV or

acute retroviral syndrome. Many individuals develop an influenza-like illness or a

mononucleosis-like illness 2–4 weeks after exposure while others have no significant symptoms.

Symptoms occur in 40–90% of cases and most commonly include fever, large tender lymph

nodes, throat inflammation, a rash, headache, tiredness, and/or sores of the mouth and genitals.

The rash, which occurs in 20–50% of cases, presents itself on the trunk and is maculopapular,

classically (Gerd et al., 2011). Some people also develop opportunistic infections at this stage.

Gastrointestinal symptoms, such as vomiting or diarrhea may occur. Neurological symptoms of

peripheral neuropathy or Guillain–Barré syndrome also occurs. The duration of the symptoms

varies, but is usually one or two weeks (WHO, 2003).

Due to their nonspecific character, these symptoms are not often recognized as signs of

HIV infection. Even cases that do get seen by a family doctor or a hospital are often

misdiagnosed as one of the many common infectious diseases with overlapping symptoms. Thus,

it is recommended that HIV be considered in people presenting with an unexplained fever who

may have risk factors for the infection (Mandel et al., 2010)

2.1.1.2 Clinical Latency

The initial symptoms are followed by a stage called clinical latency, asymptomatic HIV,

or chronic HIV. Without treatment, this second stage of the natural history of HIV infection can

last from about three years to over 20 years (on average, about eight years). While typically there

are few or no symptoms at first, near the end of this stage many people experience fever, weight

loss, gastrointestinal problems and muscle pains (Kennedy et al., 2017). Between 50 and 70% of

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people also develop persistent generalized lymphadenopathy, characterized by unexplained, non-

painful enlargement of more than one group of lymph nodes (other than in the groin) for over

three to six months (STD, 2012). Although most HIV-1 infected individuals have a detectable

viral load and in the absence of treatment will eventually progress to AIDS, a small proportion

(about 5%) retain high levels of CD4+ T cells (T helper cells) without antiretroviral therapy for

more than 5 years. These individuals are classified as "HIV controllers" or long-term

nonprogressors (LTNP). Another group consists of those who maintain a low or undetectable

viral load without anti-retroviral treatment, known as "elite controllers" or "elite suppressors".

They represent approximately 1 in 300 infected persons (Harden and Victoria, 2012).

2.1.1.3 Main Symptoms of Aids

Acquired immunodeficiency syndrome (AIDS) is defined in terms of either a CD4+ T

cell count below 200 cells per µL or the occurrence of specific diseases in association with an

HIV infection. In the absence of specific treatment, around half of people infected with HIV

develop AIDS within ten years. The most common initial conditions that alert to the presence of

AIDS are pneumocystis pneumonia (40%), cachexia in the form of HIV wasting syndrome

(20%), and esophageal candidiasis. Other common signs include recurrent respiratory tract

infections (Maura, 2007).

Opportunistic infections may be caused by bacteria, viruses, fungi, and parasites that are

normally controlled by the immune system.Which infections occur depends partly on what

organisms are common in the person's environment. These infections may affect nearly every

organ system (CDCP, 2012).

People with AIDS have an increased risk of developing various viral-induced cancers,

including Kaposi's sarcoma, Burkitt's lymphoma, primary central nervous system lymphoma, and

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cervical cancer. Kaposi's sarcoma is the most common cancer occurring in 10 to 20% of people

with HIV. The second most common cancer is lymphoma, which is the cause of death of nearly

16% of people with AIDS and is the initial sign of AIDS in 3 to 4%. Both these cancers are

associated with human herpesvirus 8 (HHV-8). Cervical cancer occurs more frequently in those

with AIDS because of its association with human papillomavirus (HPV). Conjunctival cancer (of

the layer that lines the inner part of eyelids and the white part of the eye) is also more common in

those with HIV (Hoffman, 2012).

Additionally, people with AIDS frequently have systemic symptoms such as prolonged

fevers, sweats (particularly at night), swollen lymph nodes, chills, weakness, and unintended

weight loss. Diarrhea is another common symptom, present in about 90% of people with AIDS.

They can also be affected by diverse psychiatric and neurological symptoms independent of

opportunistic infections and cancers (Edwards and Carne, 1998).

HIV is the cause of the spectrum of disease known as HIV/AIDS. HIV is a retrovirus that

primarily infects components of the human immune system such as CD4+ T cells, macrophages

and dendritic cells. It directly and indirectly destroys CD4+ T cells.

HIV is a member of the genus Lentivirus, part of the family Retroviridae. Lentiviruses

share many morphological and biological characteristics. Many species of mammals are infected

by lentiviruses, which are characteristically responsible for long-duration illnesses with a long

incubation period. Lentiviruses are transmitted as single-stranded, positive-sense, enveloped

RNA viruses. Upon entry into the target cell, the viral RNA genome is converted (reverse

transcribed) into double-stranded DNA by a virally encoded reverse transcriptase that is

transported along with the viral genome in the virus particle. The resulting viral DNA is then

imported into the cell nucleus and integrated into the cellular DNA by a virally encoded

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integrase and host co-factors. Once integrated, the virus may become latent, allowing the virus

and its host cell to avoid detection by the immune system. Alternatively, the virus may be

transcribed, producing new RNA genomes and viral proteins that are packaged and released from

the cell as new virus particles that begin the replication cycle anew (Hoare, 2010).

HIV is now known to spread between CD4+ T cells by two parallel routes: cell-free

spread and cell-to-cell spread, i.e. it employs hybrid spreading mechanisms. In the cell-free

spread, virus particles bud from an infected T cell, enter the blood/extracellular fluid and then

infect another T cell following a chance encounter. HIV can also disseminate by direct

transmission from one cell to another by a process of cell-to-cell spread. The hybrid spreading

mechanisms of HIV contribute to the virus's ongoing replication against antiretroviral therapies

(Mahiane et al., 2009).

Two types of HIV have been characterized: HIV-1 and HIV-2. HIV-1 is the virus that

was originally discovered (and initially referred to also as LAV or HTLV-III). It is more virulent,

more infective, and is the cause of the majority of HIV infections globally. The lower infectivity

of HIV-2 as compared with HIV-1 implies that fewer people exposed to HIV-2 will be infected

per exposure. Because of its relatively poor capacity for transmission, HIV-2 is largely confined

to West Africa (Varghese et al., 2002).

2.1.2 Classifications of HIV

According to WHO, two main clinical staging systems are used to classify HIV and HIV-

related disease for surveillance purposes: the WHO disease staging system for HIV infection and

disease, and the CDC classification system for HIV infection. The CDC's classification system is

more frequently adopted in developed countries. Since the WHO's staging system does not

require laboratory tests, it is suited to the resource-restricted conditions encountered in

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developing countries, where it can also be used to help guide clinical management. Despite their

differences, the two systems allow comparison for statistical purposes (Ljubin-Sternak et al.,

2014).

The World Health Organization first proposed a definition for AIDS in 1986. Since then,

the WHO classification has been updated and expanded several times, with the most recent

version being published in 2007 (Schlicht et al., 2004).

. The WHO system uses the following categories:

PRIMARY HIV INFECTION: May be either asymptomatic or associated with acute retroviral

syndrome.

Stage I: HIV infection is asymptomatic with a CD4+ T cell count (also known as CD4

count) greater than 500 per microlitre (µl or cubic mm) of blood. May include

generalized lymph node enlargement.

Stage II: Mild symptoms which may include minor mucocutaneous manifestations and

recurrent upper respiratory tract infections. A CD4 count of less than 500/µl.

Stage III: Advanced symptoms which may include unexplained chronic diarrhea for

longer than a month, severe bacterial infections including tuberculosis of the lung, and a

CD4 count of less than 350/µl.

Stage IV or AIDS: severe symptoms which include toxoplasmosis of the brain,

candidiasis of the esophagus, trachea, bronchi or lungs and Kaposi's sarcoma. A CD4

count of less than 200/µl.

The United States Center for Disease Control and Prevention also created a classification

system for HIV, and updated it in 2008 and 2014. This system classifies HIV infections based on

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CD4 count and clinical symptoms, and describes the infection in five groups. In those greater

than six years of age it is:

Stage 0: the time between a negative or indeterminate HIV test followed less than 180

days by a positive test.

Stage 1: CD4 count ≥ 500 cells/µl and no AIDS defining conditions.

Stage 2: CD4 count 200 to 500 cells/µl and no AIDS defining conditions.

Stage 3: CD4 count ≤ 200 cells/µl or AIDS defining conditions.

UNKNOWN: if insufficient information is available to make any of the above classifications.

For surveillance purposes, the AIDS diagnosis still stands even if, after treatment, the

CD4+ T cell count rises to above 200 per µL of blood or other AIDS-defining illnesses are

cured.

2.1.3 Prevention of HIV

Consistent condom use reduces the risk of HIV transmission by approximately 80% over

the long term. When condoms are used consistently by a couple in which one person is infected,

the rate of HIV infection is less than 1% per year. There is some evidence to suggest that female

condoms may provide an equivalent level of protection. Application of a vaginal gel containing

tenofovir (a reverse transcriptase inhibitor) immediately before sex seems to reduce infection

rates by approximately 40% among African women. By contrast, use of the spermicide

nonoxynol-9 may increase the risk of transmission due to its tendency to cause vaginal and rectal

irritation Murray et al., 2013).

Circumcision in Sub-Saharan Africa "reduces the acquisition of HIV by heterosexual

men by between 38% and 66% over 24 months". Due to these studies, both the World Health

Organization and UNAIDS recommended male circumcision in 2007 as a method of preventing

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female-to-male HIV transmission in areas with high rates of HIV. However, whether it protects

against male-to-female transmission is disputed, and whether it is of benefit in developed

countries and among men who have sex with men is undetermined. The International Antiviral

Society, however, does recommend it for all sexually active heterosexual males and that it be

discussed as an option with men who have sex with men. Some experts fear that a lower

perception of vulnerability among circumcised men may cause more sexual risk-taking behavior,

thus negating its preventive effects (Goering, 2012).

Programs encouraging sexual abstinence do not appear to affect subsequent HIV risk.

Evidence of any benefit from peer education is equally poor. Comprehensive sexual education

provided at school may decrease high risk behavior. A substantial minority of young people

continues to engage in high-risk practices despite knowing about HIV/AIDS, underestimating

their own risk of becoming infected with HIV. Voluntary counseling and testing people for HIV

does not affect risky behavior in those who test negative but does increase condom use in those

who test positive. It is not known whether treating other sexually transmitted infections is

effective in preventing HIV (Mandel et al., 2010).

Pre-Exposure

Antiretroviral treatment among people with HIV whose CD4 count ≤ 550 cells/µL is a

very effective way to prevent HIV infection of their partner (a strategy known as treatment as

prevention, or TASP). TASP is associated with a 10 to 20 fold reduction in transmission risk.

Pre-exposure prophylaxis (PrEP) with a daily dose of the medications tenofovir, with or without

emtricitabine, is effective in a number of groups including men who have sex with men, couples

where one is HIV positive, and young heterosexuals in Africa. It may also be effective in

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intravenous drug users with a study finding a decrease in risk of 0.7 to 0.4 per 100 person years.

The USPSTF, ini a 2018 draft, recommended PrEP in those who are at high risk (CDCP, 2012).

Universal precautions within the health care environment are believed to be effective in

decreasing the risk of HIV. Intravenous drug use is an important risk factor and harm reduction

strategies such as needle-exchange programs and opioid substitution therapy appear effective in

decreasing this risk (Baggaley et al., 2006)

Post-Exposure

A course of antiretrovirals administered within 48 to 72 hours after exposure to HIV-

positive blood or genital secretions is referred to as post-exposure prophylaxis (PEP). The use of

the single agent zidovudine reduces the risk of a HIV infection five-fold following a needle-stick

injury. As of 2013, the prevention regimen recommended in the United States consists of three

medications—tenofovir, emtricitabine and raltegravir—as this may reduce the risk further (Gerd

et al., 2011).

PEP treatment is recommended after a sexual assault when the perpetrator is known to be

HIV positive, but is controversial when their HIV status is unknown. The duration of treatment is

usually four weeks and is frequently associated with adverse effects—where zidovudine is used,

about 70% of cases result in adverse effects such as nausea (24%), fatigue (22%), emotional

distress (13%) and headaches (9%) (Baggaley et al., 2006).

Mother-To-Child

Programs to prevent the vertical transmission of HIV (from mothers to children) can

reduce rates of transmission by 92–99%. This primarily involves the use of a combination of

antiviral medications during pregnancy and after birth in the infant and potentially includes

bottle feeding rather than breastfeeding. If replacement feeding is acceptable, feasible,

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affordable, sustainable, and safe, mothers should avoid breastfeeding their infants; however

exclusive breastfeeding is recommended during the first months of life if this is not the case. If

exclusive breastfeeding is carried out, the provision of extended antiretroviral prophylaxis to the

infant decreases the risk of transmission. In 2015, Cuba became the first country in the world to

eradicate mother-to-child transmission of HIV (Hoare, 2010).

2.1.4 Vaccination of HIV

Currently, there is no licensed vaccine for HIV or AIDS. The most effective vaccine trial

to date, RV 144, was published in 2009 and found a partial reduction in the risk of transmission

of roughly 30%, stimulating some hope in the research community of developing a truly

effective vaccine. Further trials of the RV 144 vaccine are ongoing (STD, 2012).

2.1.5 Treatment of HIV

There is currently no cure or effective HIV vaccine. Treatment consists of highly active

antiretroviral therapy (HAART) which slows progression of the disease. As of 2010 more than

6.6 million people were taking them in low and middle income countries. Treatment also

includes preventive and active treatment of opportunistic infections (WHO, 2003).

Antiviral Therapy

A white prescription bottle with the label Stribild. Next to it are ten green oblong pills

with the marking 1 on one side and GSI on the other.

Stribild – a common once-daily ART regime consisting of elvitegravir, emtricitabine, tenofovir

and the booster cobicistat

Current HAART options are combinations (or "cocktails") consisting of at least three

medications belonging to at least two types, or "classes," of antiretroviral agents. Initially

treatment is typically a non-nucleoside reverse transcriptase inhibitor (NNRTI) plus two

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nucleoside analog reverse transcriptase inhibitors (NRTIs). Typical NRTIs include: zidovudine

(AZT) or tenofovir (TDF) and lamivudine (3TC) or emtricitabine (FTC). Combinations of agents

which include protease inhibitors (PI) are used if the above regimen loses effectiveness

(Hoffman, 2012).

The World Health Organization and United States recommends antiretrovirals in people

of all ages including pregnant women as soon as the diagnosis is made regardless of CD4 count.

Once treatment is begun it is recommended that it is continued without breaks or "holidays".

Many people are diagnosed only after treatment ideally should have begun. The desired outcome

of treatment is a long term plasma HIV-RNA count below 50 copies/mL.Levels to determine if

treatment is effective are initially recommended after four weeks and once levels fall below 50

copies/mL checks every three to six months are typically adequate. Inadequate control is deemed

to be greater than 400 copies/mL. Based on these criteria treatment is effective in more than 95%

of people during the first year (Kennedy et al., 2017).

Benefits of treatment include a decreased risk of progression to AIDS and a decreased

risk of death. In the developing world treatment also improves physical and mental health. With

treatment there is a 70% reduced risk of acquiring tuberculosis. Additional benefits include a

decreased risk of transmission of the disease to sexual partners and a decrease in mother-to-child

transmission (Mahiane et al., 2009). The effectiveness of treatment depends to a large part on

compliance. Reasons for non-adherence include poor access to medical care, inadequate social

supports, mental illness and drug abuse. The complexity of treatment regimens (due to pill

numbers and dosing frequency) and adverse effects may reduce adherence. Even though cost is

an important issue with some medications, 47% of those who needed them were taking them in

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low and middle income countries as of 2010 and the rate of adherence is similar in low-income

and high-income countries (Edwards and Carne, 1998).

Specific adverse events are related to the antiretroviral agent taken. Some relatively

common adverse events include: lipodystrophy syndrome, dyslipidemia, and diabetes mellitus,

especially with protease inhibitors. Other common symptoms include diarrhea, and an increased

risk of cardiovascular disease. Newer recommended treatments are associated with fewer adverse

effects. Certain medications may be associated with birth defects and therefore may be

unsuitable for women hoping to have children (Maura, 2007).

Treatment recommendations for children are somewhat different from those for adults.

The World Health Organization recommends treating all children less than 5 years of age;

children above 5 are treated like adults. The United States guidelines recommend treating all

children less than 12 months of age and all those with HIV RNA counts greater than 100,000

copies/mL between one year and five years of age (Varghese et al., 2002).

2.1.6 The problem of HIV/AIDS

AIDS is a disease which results from a compromise of the immune system caused by

HIV (WHO and UNAIDS 2007). This progressive condition reduces the effectiveness of the

immune system and leaves individuals susceptible to opportunistic infections and various forms

of cancer (Adenrele, 2007). Weight loss is also a feature (Piwoz and Premble 2000) and,

untreated, the condition is usually fatal. However, antiretroviral therapy has transformed the

prognosis such that, where treatment and support facilities are good, AIDS now has the

characteristics of a chronic disease (WHO, 2003). Transmission happens when a mucous

membrane or the bloodstream of a susceptible individual comes in contact with a body fluid

containing HIV. The most important body fluids for transmission are blood, semen, vaginal

15
fluid, and breast milk (Anthony et al., 2001). Important means of transmission include anal,

vaginal or oral sex, as well as blood transfusion or injection with contaminated hypodermic

needles (Efere, 2004). So called vertical transmission occurs when an infected mother passes the

virus onto her child during pregnancy, childbirth or breast feeding. Data on HIV and AIDS is

plentiful but of variable and uncertain quality. Much of what is reported below comes from

international agencies which collate data provided by each country. Yet, many poor countries

have rudimentary systems for data collection and it is almost certain that many of the figures

quoted are estimates at best. Nonetheless, more rigorous epidemiological data are available for

some geographies and, where these exist, they have been quoted (General Accounting Office

2001).

AIDS is now a pandemic which continues to grow despite the numerous efforts being

implemented to curb the spread of the disease (Nzimande 2010). The number of People Living

with HIV (PLHIV) continues to increase globally due to continuing spread of the virus,

population growth in many high prevalence areas and the life prolonging effect of the

antiretroviral therapy (UNAIDS, 2006).

Globally, it is estimated that 33.4 million people were living with HIV at the end of 2008

(WHO, 2010) while an estimated 2.7 million became newly infected with HIV and 2.0 million

lost their lives to AIDS (UNAIDS, 2009). The manner in which the HIV epidemic has developed

varies from continent to continent and country to country. Ghana is on the west coast of the

continent of Africa and is part of an extensive region known as sub-Saharan Africa that has,

arguably, experienced the most severe manifestations of this global epidemic. More than

twentyfive years into the epidemic, HIV and AIDS are viewed as more than simply medical issues, with

ramifications well beyond the traditional medical model of disease. The more effective responses to HIV

and AIDS are multisectoral and multifaceted. Among the sectors that should be involved in the HIV and

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AIDS response are those supporting nutrition and livelihood security. HIV and nutrition are intertwined,

as HIV affects nutritional status, and nutritional status affects the spread of HIV.

Many people in the countries served by CRS programs rely primarily on cerealcentric diets and

have never enjoyed a diet which provides 100% RDA of either macro or micronutrients. It is also

becoming increasingly evident around the world that people's food security (e.g. their physical

and economic access to nutritionally adequate food) does not automatically translate into their

nutritional wellbeing. Nutritional disorders, including undernutrition, do not necessarily

disappear once food security has been achieved. The nutritional status of a household continues

to be influenced by access to wood or other fuel, clean water, and food preparation equipment, as

well as time for feeding infants, young children, and family members with special needs.

Nutritional knowledge and cultural practices influence the amount and the type of food that each

person in the household receives. Illness and lack of access to healthcare and sanitation may

affect appetite, nutrient needs, and the ability to absorb nutrients.

Unfortunately, the adverse effects of HIV and AIDS on nutritional status occur while the body

simultaneously needs the best possible nutrition. This often results in rapidly accelerated weight

loss, malnutrition, and wasting. Adequate nutrition cannot cure HIV infection, but it is an

essential part of maintaining the immune system and physical activity and of achieving optimal

quality of life. Replenishment of macronutrients and micronutrients is an essential intervention

for people living with HIV and AIDS to mount an effective immune response to fight

opportunistic infections. It is required to optimize the benefits of antiretroviral treatment (ART)

and may significantly lengthen the period between HIV infection and the onset of active illness.

2.1.7 Economic Impact of HIV

HIV/AIDS affects the economics of both individuals and countries. The gross domestic

product of the most affected countries has decreased due to the lack of human capital. Without

17
proper nutrition, health care and medicine, large numbers of people die from AIDS-related

complications. They will not only be unable to work, but will also require significant medical

care. It is estimated that as of 2007 there were 12 million AIDS orphans. Many are cared for by

elderly grandparents (McIver et al., 2009).

Returning to work after beginning treatment for HIV/AIDS is difficult, and affected

people often work less than the average worker. Unemployment in people with HIV/AIDS also

is associated with suicidal ideation, memory problems, and social isolation. Employment

increases self-esteem, sense of dignity, confidence, and quality of life for people with

HIV/AIDS. Anti-retroviral treatment may help people with HIV/AIDS work more, and may

increase the chance that a person with HIV/AIDS will be employed (low quality evidence) (Lis

et al., 2015).

By affecting mainly young adults, AIDS reduces the taxable population, in turn reducing

the resources available for public expenditures such as education and health services not related

to AIDS resulting in increasing pressure for the state's finances and slower growth of the

economy. This causes a slower growth of the tax base, an effect that is reinforced if there are

growing expenditures on treating the sick, training (to replace sick workers), sick pay and caring

for AIDS orphans. This is especially true if the sharp increase in adult mortality shifts the

responsibility and blame from the family to the government in caring for these orphans

(Wiesenfeld et al., 2017).

At the household level, AIDS causes both loss of income and increased spending on

healthcare. A study in Côte d'Ivoire showed that households having a person with HIV/AIDS

spent twice as much on medical expenses as other households. This additional expenditure also

leaves less income to spend on education and other personal or family investment (Bryan, 2011).

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. Immunology of HIV Infection

Both CD4+ and CD8+ T cells are important in controlling HIV infection. HIV infection

stimulates production of cytokines such as TNFα, IL-6, IL-10, and IFNγ and a pool of activated

target cells in the lymphoid tissue which paradoxically help in establishing and propagating HIV

infection. Rosenberg et al. (2000) observed that HIV-specific CD4+ T-cell responses were of

high magnitude in individuals who were HIV infected but not showing progression over long

periods (long-term nonprogressors). Also, in acute viral infections such responses could be seen

but they were generally not present in patients with chronic progressive infections. In a small

number of individuals who began treatment shortly after acute HIV infection, HIV-specific

CD4+ T-cell responses were preserved.

In addition, these CD4+ T-cell responses seem to be important in controlling viral

replication after subsequent discontinuation of antiretroviral therapy. However, it has also been

found that when discontinuation of antiretroviral therapy leads to loss of virologic control, HIV-

specific CD4+ T cells are preferentially infected and depleted compared with the CD4+ T cells

of other antigen specificities. Antiviral immunity involves both the arms of the immune system.

The protective component of cell-mediated immunity involves the cytotoxic CD8 T-

lymphocytes. Schmitz and colleagues had demonstrated the effects of CD8 T lymphocytes in

monkeys experimentally infected with simian immunodeficiency virus (SIV). They observed that

prior to the depletion of CD8+ T cells, SIV replication was well controlled but after their

depletion, control of viral replication was lost. In some of these monkeys, when the CD8+ T cells

regenerated, the control of viral replication was regained (Schmitz et al., 1999).

Humoral immunity to HIV is expressed by neutralising antibodies. Anti-HIV antibodies

are able to bind cell-free virus and potentially prevent established infection in the challenged

19
host. Neutralising antibodies attaching to CD4 binding site of HIV have been identified which

appear to prevent the virus from attaching to and infecting T cells. These are natural human

antibodies—named VRC01, VRC02, and VRC03 which can neutralize over 90% of circulating

HIV-1 isolates (Zhou et al., 2010). Though HIV-specific humoral immune responses can be

detected during primary infection, they mostly comprise low-avidity env specific IgG antibodies

with little or no neutralising activity (Pilgrim et al., 1997).

Significant neutralising titers are believed to take place after chronicity has set in. HIV

evolves various strategies to establish chronicity in human body. These include viral latency,

inhibition of antigen processing or presentation, mutations in viral epitopes, and rapid clonal

exhaustion/deletion of the initially expanded virus-specific CD8+ CTL clones (Butera et al.,

1994). Initial CTL responses cause downregulation of viremia and prevent disease progression,

but later it induces the selection of virus mutants capable of escaping the immune response

(Pantaleo et al., 1993). HIV virions concentrate on the surface of follicular dendritic cells in the

germinal centres of lymphoid organs from where they are shed intermittently to establish a

steady chronic state of infection of CD4+ T cells, and to a chronic inflammatory reaction that

ultimately results in the destruction of lymphoid tissue (Pantaleo et al., 1993).

Immune activation in HIV is supported by an experiment by Pandrea et al. (2008) where

induction of immune activation was demonstrated in nonpathogenic SIV infection by an increase

in viral replication and CD4+ T-cell depletion in gut associated lymphoid tissue. Immune

activation is attributed to bystander activation in response to viral products including gene

products, immune response to HIV, translocated microbial products, new viral target proteins,

epithelial or immune cells apoptosis, and/or self-antigens (Grossman et al., 2006). High T-cell

turnover in chronic HIV infection is attributed to overlapping and nonsynchronized bursts of

20
proliferation, differentiation, and death in response to T-cell receptor- (TCR-) mediated

stimulation and inflammation (Grossman et al., 2006; Grossman et al., 2002). Antiretroviral

therapy (ART) results in a marked reduction of T-cell activation and apoptosis and helps to

decrease naive T-cell consumption and restore their numbers (Li et al., 1998). Chronic HIV

infection also causes immunological or direct virotoxic effects on gastrointestinal tract which

shows blunted villi, crypt hyperplasia, and damaged epithelial barrier with increased

permeability and malabsorption of bile acid and vitamin B 12, microbial translocation, and

enterocyte apoptosis. There is a decrease of luminal defensins and massive CD4 T-cell depletion

but high concentration of infected CD4 T cells (Brenchley and Douek, 2008).

2.2 Malnutrition

The term malnutrition generally refers both to undernutrition and overnutrition, but in

this guide we use the term to refer solely to a deficiency of nutrition. Many factors can cause

malnutrition, most of which relate to poor diet or severe and repeated infections, particularly in

underprivileged populations. Inadequate diet and disease, in turn, arebclosely linked to the

general standard of living, the environmental conditions, and whethera population is able to meet

its basic needs such as food, housing and health care.

Malnutrition is thus a health outcome as well as a risk factor for disease and exacerbated

malnutrition, and it can increase the risk both of morbidity and mortality. Although it is rarely

the direct cause of death (except in extreme situations, such as famine), child malnutrition was

associated with 54% of child deaths (10.8 million children) in developing countries in 2001

(WHO, 2004). Malnutrition that is the direct cause of death is referred to as “protein-energy

malnutrition” in this guide. Nutritional status is clearly compromised by diseases with an

environmental component, such as those carried by insect or protozoan vectors, or those caused

21
by an environment deficient in micronutrients. But the effects of adverse environmental

conditions on nutritional status are even more pervasive. Environmental contamination (e.g.

destruction of ecosystems, loss of biodiversity, climate change, and the effects of globalization)

has contributed to an increasing number of health hazards (Johns and Eyzaguirre, 2000), and all

affect nutritional status. Overpopulation, too, is a breakdown of the ecological balance in which

the population may exceed the carrying capacity of the environment. This then undermines food

production, which leads to inadequate food intake and/or the consumption of non-nutritious food,

and thus to malnutrition.

On the other hand, malnutrition itself can have far-reaching impacts on the environment,

and can induce a cycle leading to additional health problems and deprivation. For example,

malnutrition can create and perpetuate poverty, which triggers a cycle that hampers economic

and social development, and contributes to unsustainable resource use and environmental

degradation (WEHAB, 2002). Breaking the cycle of continuing poverty and environmental

deterioration is a prerequisite for sustainable development and survival.

2.2.1 Immunology of Malnutrition

Malnutrition is considered to be the most common cause of immunodeficiency

worldwide (Chandra, 1990). Malnutrition, immune system, and infectious diseases are

interlocked in a complex negative cascade (Scrimshaw et al., 2008). Malnutrition elicits

dysfunctions in the immune system and promotes increased vulnerability of the host to infections

(Enwonwu, 2006). These immune dysfunctions are referred to as nutritional-acquired immune

deficiency syndrome (NAIDS). Every type of immunological deficiency induced by malnutrition

can be included under the NAIDS umbrella.

22
2.2.1.1 PEM

Protein-energy malnutrition (PEM), now known as protein-energy undernutrition, is an

energy deficit due to chronic deficiency of all macronutrients (Morley, 2007). In children, PEM

causes widespread atrophy of lymphoid tissues, particularly T-lymphocyte areas. The thymus

involutes causing a reduction in the thymus-derived lymphocyte growth and maturation factors,

arrest of lymphocyte development, reduced numbers of circulating mature CD4 helper cells, and

impairment of antibody production to T-dependent antigens. Imbalance in Th1-Th2 activation

occurs depending on nature of stimuli and altered regulatory pathways, including responses

mediated by the nuclear factor-kB (NF-kB) (Kumar et al., 2004), a major transcription factor

involved in the development of innate and adaptive immunity. Hence the patient’s ability to ward

off infections and show recovery is compromised. However, CD8 suppressor cells are relatively

preserved. The lymphocytes not only get reduced in blood, but also impaired show T-

lymphocyte mitogenesis and diminished activity in response to mitogens (Beisel, 1996).

According to Chandra (2003), in children with PEM, there is a decrease or reversal of the

T-helper-suppressor cell ratio and total numbers of T-lymphocytes decrease due to reduced

numbers of these T-cell subpopulations. In malnourished children, changes such as dermal

anergy, loss of delayed dermal hypersensitivity (DDH) reactions, and loss of the ability of killer

lymphocytes to recognize and destroy foreign tissues were noted (Chandra, 1990). Necropsy

studies on malnourished patients have also shown profound depletion of the thymolymphatic

system and severe depression of cell-mediated immunity. Chronic thymic atrophy with

peripheral lymphoid tissue wasting along with depletion of paracortical cells and loss of

germinal centres was noted. This was suggested to have led to various types of infections from

which these patients actually died (Smythe et al., 2001).

23
 B-lymphocyte numbers and functions generally appear to be maintained though

immunoglobulin concentrations get reduced including secretory IgA (sIgA), which is responsible

for mucosal immunity. This may be due to increased bacterial adherence to nasopharyngeal and

buccal epithelial cells or altered expression of membrane glycoprotein receptors (Alverdy and

Aoys, 1991). It has been speculated that the existing antibody production is conserved or even

increased during generalized malnutrition but new primary antibody responses to T-cell-

dependent antigens and antibody affinity are impaired (Chandra, “1990). The failure of antibody

formation is reversed within a few days of protein therapy as amino acids become available for

the synthesis of immune proteins (Fernandez, 2000). It also reduces complement formation, and

interferon and lower interleukin 2 receptors (Smythe et al., 2001). In patients with severe

generalized malnutrition, functional status of the immune system should be assessed by simply

looking at the tonsils in young children. In adequately nourished children they are usually huge

but are virtually undetectable in children with severe PEM. This would indicate atrophy in the

child’s thymus, spleen, and lymph nodes, and severely compromised cell-mediated immunity

(Beisel, 1996).

Deficiencies of other nutrients also adversely affect the immune mechanisms.

Deficiencies of essential amino acids can depress the synthesis of proteins responsible for

production of cytokines released by lymphocytes, macrophages, and other body cells,

complement proteins, kinins, clotting factors, and tissue enzymes activated during acute phase

responses (Beisel, 1996). Arginine deficiency diminishes the production of nitric oxide, and

hence, the antioxidants, allowing damaging effects of free oxygen radicals (Beisel, 1996).

Arginine has also been shown to enhance phagocytes of alveolar macrophages, depress T

24
suppressor cells, and stimulate T helper cells (Tachibana et al., 2005). The “nonessential” amino

acid glutamine is necessary for lymphocytes and other rapidly growing cells.

2.2.1.2 Essential Fatty Acids

Particularly the omega-3 fatty acids, serve as the key precursors for the production of

eicosanoids like prostaglandins, prostacyclins, thromboxanes, and leukotrines that play a variety

of host defensive roles. Thus their deficiency in the diet can impair cytokine synthesis (Chavali

and Forse, 1994).

2.2.1.3 Vitamins

Vitamin A has an important role in nucleic acid synthesis, and its deficiency is also

characterized by lymphoid tissue atrophy, depressed cellular immunity, impaired IgG responses

to protein antigens, and pathologic alterations of mucosal surfaces. Experimental animals with

vitamin A deficiency have decreased thymus and spleen sizes, reduced natural killer cell,

macrophage and lymphocyte activity, lower production of interferon, and weak response to

stimulation by mitogens (Gross and Newberne, 2000). B-group vitamins like thiamin, riboflavin,

pantothenic acid, biotin, folic acid, and cobalamin can influence humoral immunity by

diminishing antibody production. Pyridoxine deficiency has also been associated with reduced

cell-mediated immunity. Folic acid and vitamin B-12 are essential to cellular replication.

Experimental deficiencies of these vitamins were shown to interfere with both replication of

stimulated leukocytes and antibody formation. In anemia due to folic acid deficiency, cell-

mediated immunity is depressed (Gross et al., 2005).

In vitamin C deficiency, phagocytic cells cannot produce tubulin, therefore, with

impaired chemotaxis, microorganisms cannot be engulfed and destroyed (Beisel, 2002). Vitamin

D acts as an immunoregulatory and a lymphocyte differentiation hormone (Scrimshaw and

25
SanGiovanni, 1997). In vitamin E deficiency, leukocyte especially lymphocyte killing power

gets reduced. In animals it was shown to interfere with antibody formation, plaque-forming cells,

and other aspects of cell-mediated immunity. At higher than recommended levels, it has been

shown to enhance immune response and resistance to disease (Tvleydani and Hayek, 1992).

2.2.1.4 Minerals

Zinc is also the fundamental component of thymic hormones and shares a similar role as

vitamin A in nucleic acid synthesis. Zinc deficiency influences both lymphocyte and phagocyte

cell functions and affects more than 100 metalloenzymes that are zinc dependent (Cunningham-

Rundles et al., 1990). During infections, reticuloendothelial cells sequester iron from the blood

and phagocytes release lactoferrin with a higher iron binding capacity than bacterial

siderophores. The net effect is to deprive the infectious agent of iron for its replication and

inhibit the spread of infection (Scrimshaw and SanGiovanni, 1997).

Iron deficiency results in impaired phagocytic killing, less response to lymphocyte

stimulation, fewer natural killer cells, and reduced interferon production (Brock, 1994).

Selenium serves as an antioxidant and contributes to antibody responses and cytotoxicity of

natural killer cells (Spallholz et al., 1990). In children with HIV infection, selenium

concentration in plasma appeared to correlate with their immune functions (Bologna et al.,

1994). Similar changes were also seen in patients with copper deficiency (Lukasewycz and

Prohaska, 1990). Copper concentrations often increase during infection as a result of stimulation

of the hepatic production of ceruloplasmin. Conversely, plasma zinc concentration often declines

due to internal redistribution to the liver. Antimicrobial systems in the neutrophils are affected by

malnutrition. These include both oxygen-dependent systems responsible for the respiratory burst,

26
and oxygen-independent systems, such as lactoferrin, lysozymes, hydrolase, and proteases

(Scrimshaw and SanGiovanni, 1997).

2.3 Malnutrition in HIV

One of the factors responsible for malnutrition in an HIV-infected person is reduced

appetite, which could be due to difficulty in ingesting food as a result of infections like oral

thrush or oesophagitis caused by Candida, a common opportunistic infection in HIV-infected

people and fever, side effects of medicines, or depression. Poor absorption of nutrients may be

due to accompanying diarrhea which may be because of bacterial infections like (CDC, 2007).

Salmonella or Mycobacterium avium intercellular; viral like CMV or parasitic infections

like Giardia, C. parvum, and E. Bieneusi; due to nausea/vomiting as a side effect of medications

used to treat HIV or opportunistic infections. 30–50% of HIV patients in developed and nearly

90% in developing countries complain of diarrhoea and malabsorption (Smith et al., 1992).

Gastrointestinal tract is the largest lymphoid organ in the body and is directly affected by HIV

infection. HIV causes damage to the intestinal cells by causing villus flattening and decreased D-

xylose absorption. This leads to carbohydrate and fat malabsorption thereby affecting fat soluble

vitamins like vitamins A and E, which are important for proper functioning of immune system.

Whereas larger amounts of nutrients are required during fever and infections that accompany an

HIV infection, they are utilised poorly by the body. This leads to loss of weight and lean muscle

tissue, further causing damage to the immune system. Lack of iron in the diet and infections such

as malaria and hookworm lead to anaemia. Anaemia causes lethargy, further reduces food intake

and nutrient absorption, and also causes disruption of metabolism, chronic infections, muscle

wasting, or loss in lean body tissue (NAPL AIDS, N1997).

27
 AIDS-related dementia or neuropsychiatric impairment may make the patients unable to

care for themselves, forget to eat, or unable to prepare balanced meals. Even in households with

HIV-infected members, nutritional impacts can be seen if the infected adult becomes too sick to

work and provide food for themselves and their families (Bijlsma, 2000; Piwoz and Preble,

2000). Dietary intake also varies inversely with level of virus, suggesting that viral replication

directly or indirectly suppresses appetite (Arpadi, 2007). Malnutrition is frequent and is

considered a marker for poor prognosis among HIV-infected subjects (Suttmann et al., 1995).

2.4 Cytokine Abnormalities in HIV and/or Malnutrition

Cytokines are substances that play an important role in coordinating inflammatory

response of the body to various external and internal stimuli. They may be proinflammatory,

which are essential to initiate defence against various pathogens, and anti-inflammatory, which

downregulate the inflammatory process by suppressing production of the proinflammatory

cytokines and balance the inflammatory response. Excess production of both are

counterproductive. The proinflammatory cytokines include IL-1β, IL-6, IL-8, TNF-α, and IL-2,

and the anti-inflammatory cytokines include IL-1 receptor antagonist, IL-4, IL-10, and IL-13

(Mosmann et al., 2006). PEM diminishes immunoglobulin (IgA, IgM, and IgG) concentrations

and cytokine production (Scrimshaw and SanGiovanni, 1997). Severe malnutrition alters the

ability of T lymphocytes to respond appropriately to IL-1 rather than simply affecting synthesis

of this monokine (Hoffman-Goetz et al., 1986). During catabolic states, interleukin 1 is released

by leukocytes which causes endocrine changes that lead to amino-acid mobilization, primarily

from skeletal muscle. These amino acids are used for gluconeogenesis in the liver, and the

nitrogen released is excreted in urine (Beisel et al., 1967). Thus, a continual conversion of

alanine carbon to glucose carbon occurs with acute infection. Bell et al. (2006) observed that the

28
immunosuppressive PGE2 production was enhanced in malnutrition. In malnourished Africans

without overt infections, increased circulating levels of inflammatory mediators (e.g., interleukin

6 (IL-6), the soluble receptors of tumor necrosis factor (sTNFR-p55 and sTNFR-p75), etc.) as

well as C-reactive protein, were seen compared to healthy controls (Sauerwein et al., 1997). In

HIV infection, both CD4+ and CD8+ T cells secrete interferon-γ (IFN-γ) in response to antigen-

specific stimulation. Another cytokine, tumor necrosis factor has been suggested as a potential

etiologic factor in HIV wasting syndrome as it has been incriminated as an appetite inhibitor

(Van Rossum et al., 2003).

2.5 Combined Effect of HIV and Malnutrition on the Immune System

Malnutrition and HIV form a vicious cycle and ultimately aim at reducing the immunity

of the patient. In both malnutrition and HIV there is reduced CD4 and CD8 T-lymphocyte

numbers (Chandra, 1999), delayed cutaneous sensitivity, reduced bacteriocidal properties

(Beisel, 1996), and impaired serological response after immunizations. According to a study,

approximately 30–60% of asymptomatic children infected with HIV malabsorb carbohydrates,

30% malabsorb fat, and 32% malabsorb proteins (Yolken et al., 1991; Guarino et al., 1993).

Whereas micronutrient deficiencies may affect replication of the invading virus, they also induce

several metabolic alterations in the body. This includes changes in whole-body protein turnover,

increased urinary nitrogen loss, and elevated hepatic protein synthesis as well as increased

skeletal muscle breakdown providing for proliferation of neutrophils, lymphocytes, and

fibroblasts, and for synthesis of immunoglobulins and hepatic acute phase proteins, manifesting

clinically as fever. It also includes hypertriglyceridemia, elevated hepatic de novo fatty acid

synthesis, decreased peripheral lipoprotein lipase activity, hyperglycemia, insulin resistance, and

increased gluconeogenesis. Serum concentrations of iron and zinc fall dramatically due to

29
redistribution within the body, with accumulation in the liver (Friis and Michaelsen, 1998).

Glutathione, which is the principle intracellular antioxidant, was reported to be reduced in

children with HIV infection, especially those showing growth failure (Rodriguez et al., 1998).

During infections, reactive oxygen molecules and pro-oxidant cytokines are released

from activated phagocytes (Schwarz, 1996) leading to increased consumption of vitamins like

vitamin E and C, and -carotene which serve as antioxidants and minerals like zinc, copper,

manganese, and selenium, which serve as components of antioxidant enzymes (Bendich, 1990).

Deficiencies of antioxidants cause increased oxidative stress which leads to apoptosis of T cells

and indirectly compromise cell-mediated immunity and may stimulate HIV replication. In cell

cultures, HIV replication was shown to be inhibited by various antioxidants but stimulated by

reactive oxygen radicals via activation of nuclear transcription factor cell gene (Kalebic et al.,

1991).

This oxidative burst may also increase viral load of blood and body fluids, such as

seminal fluid and cervicovaginal secretions, and thus increase infectivity. Maternal micronutrient

deficiencies may also increase viral load in blood, cervicovaginal secretions, and breast milk, and

hence aid in utero, intrapartum, and postnatal mother-to-child HIV transmission, respectively,

and affect immune functions and susceptibility of the unborn or young breast-fed child. HIV

infection in nutritionally deprived individuals intensifies the nutritional deficits and further

enhances cellular oxidative stress. This affects the functions of transcription factors as NF-kB

and contributes to HIV replication and progression. Although HIV attacks only a limited variety

of T-lymphocyte subspecies, AIDS-induced malnutrition can lead to the secondary development

of NAIDS through the action of proinflammatory cytokines. Also, malnutrition could hasten the

development of AIDS in an HIV-infected person (Beisel, 1996).

30
 Specific micronutrient deficiencies may also favour the host and supplementation favour

the virus. For example, HIV replication was enhanced in monocytes cultured with retinoid

(Turpin et al., 1992). Similarly, HIV nucleocapsid protein binds zinc and forms zinc finger

structures. This might imply that a high zinc intake increases the replication of HIV (Rice et al.,

1995). The role of iron in HIV infection is more complex, since iron is important for optimal

immune function, and is also a pro-oxidant and may promote replication, as has been shown

following a U-shaped curve in laboratory studies (Sappey et al., 1994). Though antioxidants

inhibit HIV replication, they may actually promote opportunistic infections by preventing the

oxidative burst which is considered important for the bactericidal properties of phagocytes [ 56 ].

So, balanced nutrition and dietary consultation with experts helps in balancing immune effects,

malnutrition, and HIV infection. FAO (2003) had stated “Food is not a magic bullet. It won’t

stop people from dying of AIDS but it can help them live longer, more comfortable and

productive lives.” Evidence-based nutrition interventions should be part of all national HIV care

and treatment programmes. Routine assessment should be made of diet and nutritional status

(weight and weight change, height, body mass index or midupper arm circumference, and

symptoms and diet) for people living with HIV (WHO, 2010).

Baum et al. (1995) had concluded that “intake of nutrients at levels recommended for the

general population does not appear to be adequate for HIV-1-infected patients’.” An active non-

HIV-infected adult requires approximately 2070 kcal/day including about 57 grams/day of

protein. An HIV-infected adult requires 10 to 15 percent more energy per day and approximately

50 to 100 percent more protein (Woods, 1999; WHO, 2005). Diet given to such patients should

be rich in carbohydrates, proteins, vitamins, and minerals. A dietician should be involved in

guiding the patients or their relatives to prepare nutritious foods. In developing countries,

31
micronutrient supplementation to high-risk populations can be provided via the primary health

care system.

Since the realization of HIV as a potential disaster for the immune system, several

advancements in its treatment, diagnosis, and supportive regimens have been made, still many

deaths in AIDS are being attributed to malnutrition and its poor management. Biochemical

evaluation of the nutritional status must be done in AIDS patients by testing blood haemoglobin

and haematocrit and serum levels of cholesterol, total protein, albumin, and transferrin.

Nutritional counselling and support could delay or even prevent the development of NAIDS and

could improve both the quality and length of their lives. Therefore, early and intensive dietary

interventions should be a fundamental part of the case management of HIV-infected individuals

at the level of ART centre itself.

2.6 Impact of HIV and AIDS on Nutritional Status

HIV and AIDS negatively impact the nutritional health of an individual in three

reinforcing ways: 1) HIV and AIDS changes the body’s metabolism so that more energy, protein,

and micronutrients are demanded and utilized. 2) Individuals with HIV and AIDS often consume

less food due to loss of appetite, mouth or throat sores, pain and nausea, side effects of

medication, or as a result of worsening household poverty and livelihood security. 3) HIV and

AIDS impair the absorption of nutrients consumed on account of diarrhea and vomiting,

damaged intestinal cells and other effects of opportunistic infections.

`These three impacts, which often occur simultaneously, can rapidly accelerate weight

loss, malnutrition, and wasting (Piwoz and Preble, 2000). A weight loss of 510%, particularly in

less than four months (Wheeler et al, 1998), is associated with an increased risk of opportunistic

infections and complications (Zachariah et al, 2002).

32
 Common AIDS symptoms include: anxiety, cough, depression, diarrhea, fever, nausea,

weight loss, vomiting, constipation, dementia or delirium, dry mouth, hiccups, incontinence of

stool and urine, itching, bedsores, mouth ulcers, trouble sleeping, vaginal discharge, pain,

respiratory problems, and tiredness (Larue et al., 1994; WHO, 2003). These medical conditions

influence the types of foods that a person can consume in favor of those that will not aggravate a

particular health condition (such as mouth sores or nausea).

In light of the above, research has demonstrated that symptomatic PLHA need

significantly more macronutrients than noninfected people or even asymptomatic PLHA. The

general recommendations for people living with HIV in resource poor environments are:

• Adults and adolescents:

• During the asymptomatic stage, 10% more energy intake requirements

• During the symptomatic stage, 2030% more energy intake requirements Children:

• During the asymptomatic stage, 10% more energy intake requirements

• During the symptomatic stage with no weight loss, 2030% more energy intake

requirements

• During the symptomatic stage with weight loss, 50100% more energy intake

requirements

While certain internationallyfocused organizations, such as FANTA, WHO, FAO, etc.,

maintain that PLHA need only the RDA of micronutrients, several research organizations in the

US and Europe argue that there is evidence of increased micronutrient needs for PLHA. The

majority of these studies are correlational in nature, showing that PLHA have decreased levels of

certain micronutrients, which does result in increased progression of HIV. As such, many

researchers argue that the results indicate that micronutrient supplementation above the RDA for

33
PLHA is needed. However, due to the very correlational nature of the research, it is not entirely

clear whether micronutrient deficiencies exist as a result of HIV and AIDS or whether these

deficiencies existed before, which have in turn exacerbated the progression of HIV. Regardless

of the direction of the relationship, it is clear that PLHA require a regular, daily diet that provides

their full RDA of micronutrients.

2.7 Impact of Nutrition on HIV Transmission

There have been numerous studies on the impact of nutrition on HIV transmission. With

regard to sexual transmission, Vitamin A deficiency has been shown to be highly predictive of

the shedding of HIV1 DNA in vaginal secretions (Mostad et al., 1997). In addition,

supplementation with multivitamins has been shown to increase CD4+ and CD8+ counts and

lower viral roads, thus improving the immune system of the HIV positive individual (Fawzi et

al., 1998). The higher the viral load and/or the lower the CD4 count, the more likely the virus

will be transmitted to an HIVpositive individual’s sexual partner. Therefore it can be deduced

that while proper nutrition does not reduce transmission nor should it be promoted as such, it

does decrease the probability of a sexually active HIV positive individual infecting others.

However, no research to date has been conducted on the links between nutrition and sexual

transmission.

Numerous studies have examined the impact of nutrition on the risk of HIV transmission

from mothers to babies as well as the health status of infants. Among HIV positive pregnant

women, multivitamin supplementation during pregnancy has been demonstrated to reduce the

chance of poor birth outcomes such as severe preterm birth, low birth weight, and small size for

gestational age (Fawzi et al., 1998). Multivitamins also appear to reduce HIV transmission

during breastfeeding, decrease death rates, and prolong HIVfree survival among infants born of

34
HIV positive mothers (Fawzi et al., 2002). In another study where HIV positive mothers were

given multivitamins during pregnancy and lactation, both HIV positive and HIV negative

children had lower risks of diarrhea (Fawzi et al., 2003).

Studies of vitamin A supplementation in pregnant and lactating women have yielded

mixed results. Some studies have shown a decrease in the frequency of poor birth outcomes

among HIV+ women (Kumwenda et al, 2002). Others have determined vitamin A to have no

significant affect on the same variables (Fawzi et al, 1998). Another study involving vitamin A

supplementation to HIV+ pregnant and lactating women demonstrated a significant reduction in

the risk of acute respiratory illness but no effect on prevalence of diarrhea or CD4+ counts in

children (Fawzi et al., 2003). In terms of the impact of vitamin A supplementation on

mothertochild transmission, some studies have shown no effect, while others have shown

negative or positive associations (Gillespie and Kadiyala, 2004). Severe vitamin A deficiency

does appear to be linked to increased rates of mothertochild HIV transmission (Semba et al,

1994).

2.8 The Role of Food and Nutrition in Prevention Of Hiv

Prevention must not be neglected in the HIV/AIDS response. With the furore that the

arrival of Anti- Retrovirals drugs (ARVs) created in the HIV/AIDS world, there has been a

tendency to place prevention on the back burner. This relative neglect came as something of a

relief to the many HIV/AIDS prevention programmes around the world that seemed to have been

having little effect on the pandemic. However, more recently, increasing knowledge about the

effects and behaviour associated with Anti-Retroviral Therapy had led many donors (e.g.

USAID), civil society organisations (e.g. the International HIV/AIDS Alliances), UNAIDS and

others to renew their emphasis on prevention.

35
 Food and nutritional security is critical to successful prevention programmes. As Box 2

suggests, people who do not have access to adequate food (and income), especially women and

girls, are more likely to be vulnerable to exposure to HIV infection by being forced into high risk

situations. Those include engaging in transactional and/or commercial sex, staying in high risk

and abusive sexual relationships because of economic and social dependency, and having to

migrate or having a mobile lifestyle in order to make a living (e.g. miners, fishermen). Migrant

and mobile communities often have poor(er) access to health care than settled populations, and

thus face a double challenge. We know that food shortage and malnutrition weaken the immune

system and generally make a person more susceptible to infections, including HIV. We also

know that a balanced and nutritional diet can strengthen a person’s immune system, making

him/her less likely to acquire opportunistic infections which then allow the easier transmission of

HIV/AIDS. Lack of proper nutrition also compromises the health status of pregnant and lactating

mothers, thereby increasing the chance of motherto- child transmission of the virus during birth

and during breastfeeding. Finally, ongoing studies are showing that a good diet for an HIV-

infected person can delay the onset of AIDS-related illness slow down the progression of the

illness.

2.9 The role of food and nutrition in treatment of HIV

Anti-Retroviral Therapy (ART) is now becoming increasingly available to poor people in

developing countries. Costs are going down, in some cases drugs are being provided free (though

other costs such as transport and user fees still represent insurmountable barriers for many

people) and there is increased political will and commitment on the widening of access. We now

know that adherence to ART and its efficacy are significantly influenced by access to adequate

food and nutrition. Medicines are strong and many need to be taken ‘on a full stomach’, which is

36
difficult for people in resource-poor settings (‘meds don’t matter if you have nothing to eat!’).

Evidence is emerging that people on ART receiving food supplementation recover much faster.

A stronger, healthier body can also increase resistance to opportunistic infections, which are

dangerous to people living with HIV, especially in resource-poor settings where preventive

health care is unavailable. Better food and nutrition, by making ART more effective, has a cost-

saving effect, not only for households and dependants, but also for the national economy.

2.10 The role of food and nutrition in care and support of HIV

While ART is being scaled up to reach those most in need, a survival period of positive

living is necessary for large numbers of other people living with HIV. Adequate and nutritious

food plays a central role in the care and support of people with HIV. In fact, we know that an

HIV-positive person has higher energy requirements than a healthy non-infected person of the

same age, sex and physical activity level. These energy requirements can range from 10-30%

higher depending on whether the person exhibits AIDS symptoms. Adequate food is thus

essential for prolonging the period of positive living and delaying the moment when ART needs

to be started. This is an additional source of cost saving for households and programmes.

Integrating food security with universal access to HIV/AIDS care would not only mean a longer

life for many individuals, but could have important spillover effects by enabling more HIV

positive people to continue active and productive lives. Those people could be expected to

continue contributing to household income, caring for families and adding to the general well-

being of their communities.

37
 CHAPTER THREE

3.1 Effect of HIV/AIDS on Nutrition

Individuals living with HIV/AIDS have special nutritional needs irrespective of whether

they are on ART or not. Proper nutrition helps to strengthen the immune system, manage

opportunistic infections, optimize response to medical treatment, and may contribute to the slow

the progression of the disease (Castleman et al, 2004). Therefore ensuring a diet with sufficient

quantities of nutrient dense foods is critical for all people living with HIV/AIDS. HIV affects

nutrition by decreasing food consumption, impairing nutrient absorption, and causing changes in

metabolism (Beisel, 1996).

3.1.1 Decreased Food Intake

Reduced food intake among PLHIV is due to painful soars in the mouth, pharynx and

oesophagus; fatigue, depression, changes in metal state, and other physiological factors.

Powanda et al. (2003) noted that poor dietary intake is due to the metabolic processes which

reduce appetite in many infections. Powanda added that poor appetite is a result of several pro-

inflammatory cytokines that are produced during infection. Wilson et al. (1979) noticed that both

systemic infections such as TB and intestinal infections including cryptosporidium and

oesophageal candidiasis contribute more to reduced food intake.

In a study by Amadi et al. (2002) it was found that encouraging food intake among

people living with HIV was associated diarrhoea was the major challenge. Anorexia may also be

caused by certain anti-retroviral drugs and this may interfere with dietary intake of the patients

until they get established on the treatment. Poor dietary intake also occurs in the background of

poverty and household food security. The conditions may get worse as PLHIV may not be

feeling well enough to work; either to grow or to earn enough to buy food (Buksuba et al., 2007).

38
Therefore the inability to eat or swallow because of painful sores in the mouth and throat, the

loss of appetite as a result of fatigue and depression, headache, diarrhoea, vomiting lead to

considerably to the reduction of food intake (Piwoz and Preble, 2000).

Macallan (1995) stated that poor dietary intake among HIV patients contributes to loss of

lean mass or poor recovery among people with severe malnutrition.

3.1.2 Reduced Nutrient absorption

HIV will interfere with the body’s ability to absorb nutrients (Beisel, 1996) if intestinal

cells are affected leading to gastro intestinal damage. Furthermore the increased incidence of

opportunistic infections such as diarrhoea cause poor absorption and use of fat-soluble vitamins

A and E. This can further compromise nutrition and immune status (Piwoz and Preble, 2000).

Malabsorption of iron also occurs under the same conditions (Castaldo, 1996).

Griffin (1990) showed that intestinal malabsorption leading to nutrient energy loss was

common in patient with HIV/AIDS. Damage caused by HIV to the intestinal villi usually leads to

malabsorption and weight loss (Macallan et al, 1993). In addition to the damage to the intestinal

villi caused by HIV, Cryptosporidium, one of the most common and more serious opportunistic

gut infections, for example, causes malabsorption and the degree of intestinal injury is related to

the number of the organism infecting the intestine (Sharpstone et al, 1999). Arpadi (2000) found

that PLHIV with severe malabsorption have lower body mass index. The study by Sharpstone et

al. (1999) showed that carbohydrate malabsorption occurs in HIV positive people, even those

without bacterial or protozoal pathogens. In addition, Murphy et al. (1999) reported that

carbohydrate malabsorption was severe especially among people immune depression.

39
3.1.3 Altered Metabolism

Changes in metabolism in PLHIV occur as a result of the immune system’s response to

HIV infection. When the body mounts its acute phase response to infection, it releases pro-

oxidant cytokines and other oxygen-reactive species. These cytokines produce several results, for

example fever (increasing energy requirements) (Piwoz and Preble, 2000). Muscle tissue is broke

down to provide amino acids for the synthesis of immune protein and essential enzymes. WHO

(2003) also noted that asymptomatic people living with HIV/AIDS increase energy intake by

10% while the symptomatic increase energy intake by 20-30% over the requirement for healthy,

HIV negative people of the same age, sex, and physical activity level.

3.2 HIV/AIDS, Nutritional Status and Immune System

Timely improvement in nutritional status can help strengthen immune system, thereby

reducing the incidence of infections, preventing loss of weight and lean body mass, and delaying

disease progression. Therefore HIV has less chance to develop in to AIDS in a person who is

well nourished. Nutritional care and support helps people living with HIV to manage HIV-

related complications, promotes good responses to medical treatment, and improves the person’s

quality of life by maintaining strength, comfort, level of functioning, and human dignity

(FANTA, 2004). A well-nourished person has a stronger immune system for coping with HIV

and fighting illness.

3.3 Dietary Patterns and Nutrition Related Life Styles in HIV/AIDS

Having proper nutrition in HIV/AIDS includes; consuming diversified or variety of foods

that will provide the body with the necessary energy, protein, fats, vitamins and minerals (MOH,

2006). According to the Kenyan national guidelines on nutrition and HIV/AIDS (2006), dietary

40
intake along with regular exercise, controlling weight, avoiding alcohol intake, smoking and

other narcotic drugs are make up nutrition related healthy life styles.

3.3.1 Food Diversity in Management of HIV/AIDS

Dietary diversity, the consumption of an adequate variety of food groups, is an aspect of

dietary quality and can be considered an indicator of general nutritional adequacy (Nontobeko et

al., 2008). Low dietary diversity is associated with specific nutrient deficiencies. The main

reason for promoting food diversification is that, no single food except breast milk contains all

the nutrients the body needs in the right quantities and combinations (MOH, 2006). Another

study by Bukusuba et al. (2007) noted that there is very low dietary diversity in developing

countries, the majority of studied households reported consuming fewer than six food groups

(low quality diet) moreover their daily diet was dominated by one main staple food group mainly

cereals. According to FANTA (2004), maintaining adequate nutritional status means consuming

a variety and adequate quantity of foods to meet energy, protein, and micronutrients needs.

PLHIV should eat balanced and diverse diets consisting of starchy staples with cooked legumes,

nuts and animal foods, fat and oil, fruits, and vegetables.

Nontobeko et al (2008) showed that in South Africa, diets for PLHIV were significantly

less diverse than those of HIV negative individuals. However a balanced diet will ensure that the

individual consumes sufficient nutrients to maintain energy, normalize weight, and ensure the

body’s proper functioning. The main types of food people need to live a healthy life include

energy-providing foods (i.e. carbohydrates, fats), body-building foods (i.e., proteins, minerals),

and protective foods (i.e., vitamins, minerals) (FANTA, 2004).

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3.3.1.1 Energy Giving Foods

This includes the carbohydrates, fats and oils that are in food groups like cereals, tubers,

and plantain. Staples are good sources of energy. Staple foods should be the part of every meal

and form the base and largest part of daily meals.

Cereals

Cereals are one of the staple foods in Africa and other parts of the world. Examples of

cereals are maize, sorghum, millet, rice etc. Some cereals such as millet and sorghum contain

some proteins and iron. However, they don’t contain adequate nutrients on their own. Nutrients

from staple foods may not be available to the body unless eaten in combination with other foods

(MOH, 2006).

Tubers and Plantain

Tubers are known as good sources of energy. The most common tubers and roots that are

consumed in Nigeria are mattoke (plantain,) sweet potatoes, cassava, yams, are among others

(MOH, 2006).

Fats/Oils and Dairy products

Fats and oils are the richest sources of energy. One gram of fat provides twice the energy

of one gram of carbohydrate. Therefore people only need small amount of fats because excessive

consumption of fats may predispose individuals to obesity and heart disease. Vegetable oils are

obtained from corn, simsim, sunflower, cotton seed, shear butter, palm oil and margarine.

Animal source fats include butter, cheese, whole milk, fatty meat and fish (including fish oil)

(MOH, 2006). Fat also facilitate absorption and utilization of some essential vitamins such as A,

E, D and K.

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2.4.1.2 Body-Building Foods

Proteins are referred to as body-building foods. They are essential for cell growth,

support the function and formation of the general structure of all tissues, including muscles,

bones, teeth, skin and nails. The two main types of proteins are: plant source proteins and animal

source proteins. Plant source proteins include beans and peas of different varieties, greengrams,

groundnuts, soybeans and simsim. Where as animal source proteins include meat, milk

(including products like cheese, yoghurt and fermented milk), fish and eggs. Other sources of

protein include nsenene (grasshoppers) and white ants. Williams et al. (2003) found that high

protein diets are associated with increased gain of Body cell mass among HIV positive persons.

Legumes

MOH (2006) recommends to include legumes in everyday diet as frequently as possible.

Legumes include beans, peas, lentils, groundnuts, and soybeans. Legumes provide nutrients that

are needed to develop and repair the body as well as building strong muscles. As compared to

animal products, legumes provide cheaper source of protein and energy. Legumes when eaten

with staple foods such as maize, millet, sorghum and rice, improve quality the diet. Legumes are

also rich in other essential nutrients including: the B vitamins, vitamin E, iron, and calcium.

Animal Products

Animal products supply good quality proteins, vitamins, minerals and extra energy.

Micronutrients in animal products include iron, vitamin A, selenium and zinc that strengthen

muscles and immune system. Animal products include beef, chicken, fish, eggs, offal and milk

(MOH, 2006).

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3.3.1.3 Protective Foods

Fruits and vegetables are known as protective foods because they provide vitamins and

minerals that are important in strengthening the immune system. Vegetables and fruits are also

major sources of fibre and roughage required for bowel movement and prevention of

constipation (MOH, 2006a).

Vegetables

Vegetables add taste, flavour and colour to our meals. Common vegetables include:

doodo, nnakati, malakwang, eboo, spinach, kale (sukumawiki), pumpkin leaves, cowpea leaves,

carrots, cassava leaves, and green peppers. Cabbage is a vegetable that is important mainly as

roughage. Vegetables contain useful immune substances called beta-carotenes. In many cases,

vegetables are seasonal in availability, quality and prices (MOH, 2006a). Kristy (2003) noted

that HIV patients who consume of high fibre foods have shown lower fat deposition in their

bodies.

Fruits

A variety of fruits grow in Nigeria . The deep yellow or orange coloured fruits are richer

in vitamins, particularly beta-carotenes and vitamin A. Such fruits include avocadoes, mangoes,

pawpaw, pumpkin, passion fruit, pineapple and jackfruit. Oranges, lemons and other citrus fruits

are rich sources of vitamin C. Like vegetables, most fruits in Nigeria are seasonal (MOH,

2006a). Fruits are known as good sources of antioxidant substances (FANTA, 2004).

3.3.2 Meal Frequency

The guideline by ministry of health (2006) on nutrition for PLHIV encourages people

living with HIV to increase the amount and frequency of eating meals that are rich in energy,

protein and plenty of fruits and vegetables. It also encourages eating of two to three snacks in

44
addition to the main daily meals (Breakfast, lunch and Supper). By increasing meal frequency,

PLHIV can meet the higher energy requirement of the body which is due to infection.

3.3.3 Nutrient Requirements of PLHIV

In general PLHIV have different nutritional requirements than HIV negative person.

Further more the nutrient requirements with in PLHIV can also be different depending on the

progress of the infection. Macallan (1995) stated that poor dietary intake among HIV patients

contributes to loss of lean mass or poor recovery among people with severe malnutrition.

3.3.3.1 Macronutrient Requirements

Energy Requirement

Energy requirements are elevated with high viral load, fever, opportunistic infection, the

need for weight gain and the increased energy cost of breathing in respiratory infections (Xuereb,

2004). According to WHO (2003), recommendation, for symptomatic HIV positive adults should

increase energy intake by 10% and 20-30% during the symptomatic phase over the requirement

for healthy HIV positive people of the same age, sex, and physical activity level. These

recommendations are also for PLHIV persons, including those taking HIV-related medications

such as ARVs (FANTA, 2004).

Researchers in United States found that weight gain and /or weight maintenance could be

achieved among asymptomatic HIV positive individuals and among HIV positive people in the

early stages of AIDS with no secondary infections, who received at least one day, high-energy,

high protein, and liquid food supplementation along with nutritional counselling (Stack et al.,

1996).

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Protein Requirement

According to WHO (2003), data are insufficient to support an increase in protein

requirements due to HIV infection. HIV-positive persons do not require more protein than the

level recommended for healthy HIV negative persons of the same age, sex, and physical activity

level, that is, 12% to 15% of total energy intake. However, Xuereb (2004) noted that, since

energy requirements are higher, protein intake should increase proportionately with efforts to

increase energy intake. On the other hand, there is the view that requirements are consistently

elevated to provide substrate for immune cell replication (the acute phase response) lean body

mass maintenance as well as during periods of septicemia when protein needs are dramatically

elevated to attenuate hyper catabolism of somatic protein stores. Protein deficiency is closely

associated with energy deficiency: both are often deficient in HIV/AIDS.

Waterlow et al. (1992) stated that establishing the amount of protein which an individual

needs to maintain body composition and body function is difficult. Current evidence on

macronutrient and HIV infection by WHO (2005) suggested that HIV positive individuals in a

state of dietary protein depletion need greater amounts of protein. However more evident from

animal and human studies models on septic or catabolic states similar to HIV/AIDS show

inadequately utilised amino acid from increased intake (Garlick et al., 1980, Tomkins et al.,

1983 and Powell, 1984).

Shabret et al. (1999) showed that intake of protein supplements containing amino-acid

glutamine along with anti oxidants, showed a significant gain in body weight and body cell mass

in HIV patients who had lost weight. Another cross-sectional study in PLHIV found that, protein

intake was highly correlated with lean body mass (Difranco et al., 1996). Selberg et al. (1995) in

46
his study of wholebody protein turnover in HIV patients found that it is correlated to BCM and

protein intake.

Fat Requirement

According to the WHO (2003) guidelines, there is no evidence that fat requirements are

different during HIV infection. However, certain ARVs or certain infection symptoms such as

diarrhoea may require changes in the timing or quantity of fat intake (FANTA, 2004). Despite

the well documented evidence on fat malabsorption in HIV/AIDS, Castaldo et al. (1996)

suggested that it was possible to achieve nutritional rehabilitation using diets rich in fat.

3.3.3.2 Micronutrient Requirements of PLHIV

Micronutrients (Vitamins and minerals) are important in the HIV-nutrition relationship

due to their critical roles in cellular differentiation, enzymatic processes, immune system

reactions, and other body functions (Piwoz and Preble, 2000). Several micronutrients are

required by the immune system and major organs to fight infectious pathogens. Persons with

inadequate intake of micronutrients have difficulty in resisting infection. As a result, the role of

micronutrients in HIV/AIDS takes on special importance in individuals and populations with

marginal or low micronutrient intakes (Friis and Michaelson, 1998). Although micronutrients

requirements are likely to be reduced when the HIV patient is put on ARV, micronutrient

deficiencies may persist and affect absorption and efficacy of drugs. The following are some of

the important micronutrients in management of HIV (Raten, 2005).

Vitamin A

Vitamin A is one of the most important nutrients in management of HIV. Vitamin A has

a greater role in maintenance of epithelial cells, mucous membranes and the skin. It is also

important in immune system function and resistance to infections and many others (Piwoz and

47
Preble, 2000; Stephenson, 2001). The role of vitamin A was also seen in a study by Coutsoudis

(1995) where vitamin A supplementation reduced morbidity due to diarrhoea by 50%. Main

dietary sources of vitamin A are liver, dairy products, kidney, egg, some fishes, yellow fleshed

sweet potato, pumpkin, palm oil, carrot, dark green leafy vegetables, fruits, such as papaya and

mango (FANTA, 2004).

Vitamin B12

Vitamin B12 is important for new cell development and maintenance of the nerve cells.

Low serum B12 intake that arise from either poor intake or other problems are associated with

neurological abnormalities, reduced CD4 T-cell counts; increased bone marrow toxicity that is

associated with the use of Ziduvodine (Tang and Smit,1998). Baum et al. (1998) also found that

improvements in B12 levels were associated with increase in CD4 count. The main sources of

B12 are Red meat, fish, chicken, shellfish, cheese, eggs, and milk (FANTA, 2004). Since the

sources are vitamin B12 animal source, HIV positive person who are vegetarian should consider

getting the vitamin from other sources like nutrient supplements (Piwoz and Preble, 2000).

Vitamin E

Vitamin E is known for its protection of cell structures (as antioxidant) and facilitates

resistance against diseases (FANTA, 2004). Supplementation of vitamin E, even more than the

recommended levels has been shown to increase immune response and resistance to disease

(Meydani and Hayek, 1992). HIV patients are therefore encouraged to take more vitamin E

source foods in order to reduce the oxidative stress created by HIV and related opportunistic

infections that may increase utilization of Vitamin E. Sources of vitamin E are leafy vegetables,

vegetable oils, peanut, egg yolk, vegetables, nuts, and liver (FANTA, 2004).

Zinc

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 Zinc is known for its role in functioning of many enzymes, immune reactions, transport

of vitamin A and also it acts as an antioxidant (FANTA, 2004). Meat, fish, poultry, shell fish,

whole grain cereals, legumes, vegetables and pumpkin seeds are the main sources of zinc

(FANTA, 2004). In populations where there is a mild and marginal zinc deficiency, problems

like depressed immunity, damage to epithelial lining of the intestine and respiratory tract are

common (Shankar and Prasad, 1998). Zinc may have indirect effect on controlling of weight loss

and wasting where as zinc inhibits tumour necrosis factor (TNF), a cytokine that is important in

triggering the process of wasting in HIV infection (Baum, 2000). Another study by Mocchegiani

(1995) showed that zinc supplementation reduced the incidence of opportunistic infections,

stabilised weight and CD4 count among adults with AIDS who are receiving ARV therapy.

Selenium

Selenium is believed to play an important role in metabolising reactive oxygen species or

free radicals and reducing oxidative stress. This is because selenium is an essential cofactor for

some antioxidant enzymes (Piwoz and Preble, 2000). Baum and Shor (1998) noted that selenium

deficiency impairs the immune system and has been associated with faster HIV disease

progression and reduced survival in adults. Main sources of selenium are meat, eggs, whole

grain, plants grown in selenium rich soils and sea foods.

Iron

Iron has a vital role for all cells in generating of energy. Iron is required by the body to

produce new cells, amino acids, and hormones, as antioxidant and it is transported throughout

the body to be used as needed. Iron is found in muscle, in blood, and in many enzymes required

for metabolism (Piwoz and Preble, 2000). Dietary sources of iron include red meat, poultry,

shellfish, egg, peanut, groundnuts, deep green leafy vegetables, lentils, beans, cereals (FANTA,

49
2004). Iron deficiency occurs mainly when the iron stores are depleted and the dietary intake of

the patient can not compensate for these requirements. Anaemia can also be caused by

Zidovudine an antiretroviral drug, which suppresses bone marrow function and synthesis of red

blood cells (Piwoz and Preble, 2000).

3.3.4 Nutrition Related Healthy Life Styles

Physical activity is a fundamental way to improve physical and mental health. It

improves physical fitness, lessens depression, improves appetite, relieves constipation, improves

intestinal absorption, improves muscle tone and eliminates excess fat. Progressively resistant

exercises reduce fat levels in blood, hence decreasing the risk of heart disease and diabetes, and

improving lean body mass (LBM). Therefore the impact of physical activity leads to a better

quality of life (MOH Kenya, 2006).

More activity may be required for weight reduction among the overweight. However,

physical activity should always be within sufficient energy intake, otherwise it may cause

unwanted weight loss. Service providers should assess a client’s strength, and recommend

suitable and various physical activities. For example, a hand grip will assess muscle strength and

this measure correlates well with muscle endurance (glycogen levels) and hydration (Schlenzig

et al, 1993). Exercise coupled with healthy eating is needed to balance food intake with physical

activity to maintain a healthy weight. The importance of exercise is often overlooked among

PLHIV. However, regular exercise, especially resistance training, has been found to assist with

building lean body mass. Patients who exercise are stronger and better able to manage the

activities of daily living independently (Florindo, 2004).

Moderation in the consumption of tea, coffee, sodas or other related drinks that may

interfere with food intake, absorption and utilization medicine is important. Poor habits such as

50
smoking, alcohol consumption and drug abuse that may affect food and nutrient intake; increase

oxidative stress; and decrease the efficacy of some medications and immunity. Geetanjali et al.

(2007) in his urban HIV patients cohort, found that hazardous alcohol use and active drug use

were each independently associated with decreased antiretroviral uptake, adherence, and viral

suppression. Therefore PLHIV are advised to stop consuming of alcohol, smoking or chewing

tobacco and using illicit drugs while on ART.

3.4 Antiretroviral Drugs and Nutrition

3.4.1 Nutrition related effects of ARVs

ARVs interact with food and nutrition and result in positive and negative outcomes

(Castleman et al, 2004). Some positive effects of ARVs on dietary intake are intense hunger and

craving for certain foods. This is because the body is starting to rebuild itself and needs the

energy that comes from food (Alliance, 2007). On the other hand, the side the negative effects

that arise from taking of ARVs include nausea, taste changes, mouth ulceration, loss of appetite,

abdominal pain, constipation, flatulence, headache, diarrhoea and vomiting which are common

especially in the early stage of treatment (FANTA, 2004; Hoffmann et al., 2006). These

problems lead to reduced food intake or reduced nutrient absorption that exacerbates weight loss

and nutritional problems experienced by PLHIV. Moreover a study in the USA showed that 30%

of drug interruption in the first 90 days is attributed to nausea, vomiting, and other

gastrointestinal effects of ARVs (Chen et al., 2003). This drug interruption can lead to health

deterioration and risks of malnutrition in patients.

3.4.2 First Line Antiretroviral Regimens

Antiretrovirals (ARVs) are medicines used to treat HIV infection. They reduce the

amount of HIV (the viral load) in the body, which protects the immune system and allows it to

51
recover. ARV treatment is a life long treatment (Alliance, 2007). According to a report by United

States president’s emergency plan for AIDS relief, about 145,000 individuals were receiving

ARVs by September 2008 (PEPFAR, 2009). HIV positive patients, who are eligible to start

ART, start with the first line regimens. A first line ART is an antiretroviral drug regimen that is

recommended for patients who have never been exposed to ARVs or those who were on

treatment but stopped all drugs at once for more than three months (MOH, 2003). In initiating of

ART a three drug combination should be used. This combination may contain two Nucleo

Reverse Transcriptase Inhibitors (NRTIs) plus one Non Nucleo Reverse Transcriptase Inhibitors

(NNRTI) or a Protease Inhibitors (PI) (MOH, 2003).

3.5 Best Practices and Programming Options

3.5.1 Fortification

Interest in fortification has been given further emphasis in the context of the HIV and

AIDS pandemic, where indications are that multiple micronutrients can improve survival and

quality of life if given throughout the course of infection. During the recent emergency response

in Southern Africa, the World Food Program (WFP) promoted and implemented the large scale

milling and fortification of donated food aid, using a standardized premix (WFP, 2003).

The World Health Organization (WHO), in a consultative meeting held in April 2005,

reaffirmed its commitment to “accelerate the fortification of staple foods with essential

micronutrients” as part of a purposeful response to the HIV and AIDS pandemic (WHO, 2005).

At this time, however, there is insufficient evidence to drive the development of a new or

enhanced fortificant blend specifically designed for PLHA: the standard premix for cereals will

be used until clearer evidence emerges. NGOs have a strong history of involvement at various

levels of fortification work.

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3.5.2 Supplementation

Supplementation refers to the provision of vitamins or minerals by mouth or injection to

provide sufficient stores of a specific nutrient for a defined period of time. (e.g. Vitamin A for

children under 5 years old, iron and folic acid for pregnant women). Research has recently

shown (Fawzi et al., 2005) that a multivitamin supplement for symptomatic PLHA improved

overall health.While there is a strong evidence base for the efficacy and costeffectiveness of

these targeted programs, there is insufficient evidence to support the provision of multivitamin

supplements to all asymptomatic PLHA on a population scale, as there is still a lack of scientific

data that identifies the effects of supplementation of HIV progression in asymptomatic

individuals. In addition, mass supplementation as a populationbased strategy may be

7
unsustainable and costly in the long term. As such, many programs attempt to provide the

necessary nutrients through locally produced or homegrown food stocks versus the provision of

vitamins and minerals.

3.5.3 Public Health Measures

Public health measures are generally designed to address issues that may interact with

micronutrient malnutrition such as poor sanitation, access to potable water, malaria control, and

management of intestinal parasites. It is generally considered a public health mandate to

contribute to monitoring and advocating for general food/nutrition security, and to protect the

general public from the commercial marketing of untested diets, remedies, and therapies for

PLHA. As with Nutrition Education, the NGO sector has a strong and proud history in health

programming that could be extremely influential.

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 CHAPTER FOUR

4.1 Conclusion

The HIV virus attacks the immune system. In the early stages of infection a person shows

no visible signs of illness but later many of the signs of AIDS will become apparent, including

weight loss, fever, diarrhoea and opportunistic infections (such as sore throat and tuberculosis).

Good nutritional status is very important from the time a person is infected with HIV. Nutrition

education at this early stage gives the person a chance to build up healthy eating habits and to

take action to improve food security in the home, particularly as regards the cultivation, storage

and cooking of food. Good nutrition is also vital to help maintain the health and quality of life of

the person suffering from AIDS. Infection with HIV damages the immune system, which leads to

other infections such as fever and diarrhoea. These infections can low-er food intake because

they both reduce appetite and interfere with the body's ability to absorb food. As a result, the

person becomes malnourished, loses w-cight and is weakened.

One of the possible signs of the onset of clinical AIDS is a weight loss of about 6-7 kg

for an average adult. When a person is already underweight, a further weight loss can have

serious effects. A healthy and balanced diet, early treatment of infection and proper nutritional

recovery after infection can reduce this weight loss and reduce the impact of future infection.

A person may be receiving treatment for the opportunistic infections and also perhaps

combination therapy for HIV; these treatments and medicines may influence eating and nutrition.

Good nutrition will reinforce the effect of the drugs taken. When nutritional needs are not met,

recovery from an illness will take longer. During this period the family will have the burden of

caring for the sick person, paying for health care and absorbing the loss of earnings while the ill

54
person is unable to work. In addition, good nutrition can help to extend the period when the

person with HIV/AIDS is well and working.

55