Nutrition and HIV

Lecture 2
Dr Janetta Harbron PhD, RD(SA)
Outline
• Pre vs. Post HAART HIV & nutrition

• Nutritional problems in HIV

• Nutritional therapy

• PMTCT
South African resources on VULA – reference material
Old era of HIV/AIDS nutrition
For every 1% loss
Late presentation with AIDS weight lost →→ 11%
increase in the risk of
ARVs only started once clinically indicated death.

With 10% loss from

Profound malnutrition (undernutrition) and wasting
baseline weight →→ 6X
also referred to as HIV-associated wasting syndrome increased relative risk
of mortality
Nutritional approaches at the time
• to avoid malnutrition Siddiqui et al. 2022
• as adjunct therapy to delay HIV progression
• to delay breastfeeding transmission Siddiqui et al. 2022
New era for HIV nutrition
Increased awareness and
universal ARV role-out
Improved viral suppression &
PMTCT
Obesity, metabolic
complications
Longer lifespan, increased
NCD risk
But in the last two decades, significant
improvements in treatment, care of PLHA, and
with the advent of newer Highly active
antiretroviral therapy (HAARTs), wasting
syndrome is not seen so frequently associated
with HIV as before, instead, NCDs, including
obesity, are being seen more frequently
associated. Hence, HIV has now become a
double edged sword, with one side
representing undernutrition and wasting and
the other side overweight and obesity.
Patel et al. 2022
HIV undernutrition
Two types of weight loss:
1. Starvation-related wasting:
• Lack of nutrient substrates in the body due to decreased
intake / increased losses / malabsorption increased needs
(increased resting energy expenditure)

2. Cachexia-related wasting:
• Disproportionate loss of lean body mass (LBM) due to
altered metabolism
 Nutrient intake may be adequate
 (gluconeogenesis – producing glucose from amino-acids)
 Reduced use of fat – accrues (stored) --- lipodystrophy
HIV undernutrition
HIV wasting syndrome (HIVWS)
As PWH are living longer, they
remain at higher risk of age-
10% involuntary weight loss from baseline associated comorbidities
including HIV-associated wasting
and either:
(HIVAW). HIVAW increases
diarrhoea > 1 month morbidity and mortality but has
or received little attention in the
era of modern ART.
weakness and fever > 1 month Siddiqui et a. 2022
not
explained by other condition, e.g. TB, cancer
HIV undernutrition
causes
HIV undernutr.
causes
Metabolic complications –
increased obesity and NCD RISK
Multifactorial aetiology and varied presentation

 Chronic inflammation

 Dyslipidaemia (elevated TG, low HDL) mainly

from some PIs

 Insulin resistance from some PIs and NRTIs

Obesity and insulin resistance prevalent in SA

HIV associated lipodystrophy
syndrome
Lipohypertrophy
 Visceral fat central adiposity
 Dorsocervical fat pad & breast
hypertrophy (Buffalo hump)

Peripheral subcutaneous lipoatrophy

 Wasting:
 Arms, legs, buttocks, face
 Rare with newer generation ARVs
Nutrition management goals
Optimize nutritional status
• Prevent, rather than reverse
• Maintain lean body mass (growth in children)
• Maintain normal bodyweight to reduce comorbidities
• Prevent nutrient deficiencies

Reduce severity of HIV-related symptoms

Enhance adherence & effectiveness of ARVs
Manage metabolic complications, e.g. diabetes, hypertension
Improve quality of life
Nutrition care process
Screening and referral

Assessment (A,B, C, D)
• (Anthropometric, Biochemical,
Clinical and Dietary)

Diagnosis

Intervention

Monitoring & evaluation

Assessment: Medical information
Assessment: Anthropometry
Weight, Height = BMI

Waist circumference

Mid-upper-arm circumference
(MUAC).

Bioelectrical impedance analysis (BIA) = measures body

composition

Measurements of skinfold thickness = %body fat

Biochemical assessment
Serum protein – albumin interpreted with caution

Inflammatory markers

Micronutrients – Iron, Folate, B12, Zinc?

Lipids, glucose
Clinical assessment
Identify symptoms/ side-effects/ illnesses associated
with HIV/AIDS infection that can affect nutritional
status.
• appetite
• fever
• nausea, vomiting
• difficulty with swallowing
• mouth and/or throat sores, oral thrush
• muscle wasting
• fatigue, lethargy
• TB
Diet history assessment
Nutritional requirements
Nutritional requirements
Micronutrients:
• Intake often inadequate
• 100% RDA supplement can be recommended
• Mega-dosing may be detrimental, e.g. Vitamin A
and zinc
• Possible benefit of selenium, Vitamin D on
reducing HIV progression
• Investigate anaemia for nutrient contributors i.e.
iron, B12, folate, B6, copper
Route of nutrition
1. Oral diet based on food

2. Supplementation with macronutrient or

micronutrient supplementation

3. Enteral nutrition via nasogastric tube or

gastrostomy tube

4. Parenteral feeding
Management of metabolic risks for
NCDs
Lifestyle modifications as for non-infected
population

Nutrition education, counselling, diet manipulation

Healthy diet: lower in saturated fat, refined

carbohydrate, salt; higher/ rich in healthy fats,
wholegrains, fruits and vegetables
Obesity management
GI Symptom management
Food safety
Food/Nutrient-drug interactions
PMTCT
PMTCT
Perinatal transmission risk as high as 15 – 45%

>95% of pregnant women in SA receive ARVs

In SA, with ARV’s and prophylactic treatment, the

2016 MTCT rates:
- 6 weeks transmission rate = 1.5%
- post 6 weeks transmission rate= 3.1%
- Total transmission rate = 4.6%

UNAIDS, 2017 estimates

PMTCT - breastfeeding
Previously women were provided a risk-based
choice:
Small risk of transmission with EXCLUSIVE
BREASTFEEDING = (5%)
Or
No risk of feeding transmission but higher risks of
infectious diseases with formula feeding

Formula feed was previously provided to mothers

free-of charge
 PMTCT - breastfeeding
Currently, SA follows WHO 2016 guidelines:

All pregnant women on ARVs and infants at least 6 weeks

post-exposure prophylaxis (transmission risk <<1%)

AND
Exclusive breastfeeding (1st 6 months), start
complementary feeding at 6months and continue BF for 2
years and beyond.

UNLESS
Mother on second or third-line ART for at least 3 months
and viral load still above 1000 copies/ml
• Formula feed provided by DOH
 PMTCT - breastfeeding
WHO 2016 guidelines:
Prevent re-infection
Adherence to ARVs

Support breastfeeding
• WHO 10 steps

Mixed feeding discouraged but not

contraindicated
• Some breastfeeding better than none
• Gradual cessation
 PMTCT - breastfeeding
Formula feeding can still be chosen by mother if:

Acceptable: family is supportive of FF

Feasible: safe water and sanitation
Affordable
Sustainable: for 6 months
Safe: preparation to decrease risk of diarrhoea &
malnutrition + health care access
Food insecurity and HIV
HIV depletes human, financial, physical capital, reducing
earning capacity

Negatively impacts on ARV adherence

Unhealthier diet higher in refined carbohydrates, sugar,

salt, lower in fruit and vegetables, protein, diversity

Access to the DOH Nutrition Therapeutic Programme

(NTP)
• Provides access to nutritious foods
• Some stigma attached?
Resources
Practice Paper of the Academy of Nutrition and Dietetics: Nutrition
Intervention and Human Immunodeficiency Virus Infection. J Acad Nutr Diet.
2018;118:486-498.

Mankal & Kotler. From Wasting to Obesity, Changes in Nutritional Concerns in

HIV/AIDS. Endocrinol Metab Clin N Am 43 (2014) 647–663

Mahan & Raymond (2016). Krause’s Food Nutrition and Diet Therapy, Chapter
37

Temple N & Steyn NP (2016): Community Nutrition for Developing Countries.

UNISA: University of South Africa Press. Chapter 10. (sections 3, 5 & 6)

Guideline for the Prevention of Mother to Child Transmission of HIV and other
Transmittable Infections (2018). South African National Department of Health