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NUTRITION SUPPORT IN HIVAIDS

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Title: NUTRITION SUPPORT IN HIVAIDS


1
  • NUTRITION SUPPORT IN HIV/AIDS
  • BY
  • DR. CHARLES MUGISHA (PHD)
  • CONSULTANT NUTRITIONIST
  • MINISTRY OF HEALTH /MULAGO HOSPITAL COMPLEX
  • TEL 256(0) 77-2-348442

2
  • Objectives for the training
  • At the end of the sessional training ,the
    trainees should be able to
  • Describe the effects of HIV infection and
    nutrition on each other
  • Discuss special nutritional needs related to HIV
    infection AIDS , pregnancy , women and children.
  • Discuss HIV infection and breast feeding /breast
    milk substitutes
  • Describe the effects of anti retroviral drugs
    /therapy (ARVs/ART) and nutrition on each other
    (briefly)

3
  • Preamble
  • The immune system
  • Most powerful natural healing machinery in the
    body .
  • Has the inordinate ability to heal the body from
    all diseases.
  • Provided it is adequately supplied with all the
    nutrients it requires.
  • Our best defence against disease and illness is a
    healthy immune system.
  • Boost immune system through adequate nutrition

4
  • A properly working immune system is a function of
    good nutrition .
  • For example
  • If Yours body has a strong enough immune system
  • You can be infected with a flu virus and not get
    flu
  • You can be infected with the TB germ and not
    develop tuberculosis
  • You can even be infected with HIV and not
    develop AIDS.

5
  • Importance of nutrition to human health and
    disease management
  • Nutrition is a basic scientific discipline
  • It studies the relationship between food and
    human health
  • Nutrients and biologically active ingredients in
    the food are used for
  • Normal growth and development ,especially in
    children
  • Mental development is a function of a adequate
    nutrition
  • Used in the maintenance of tissues in a normal,
    healthy state.

6
  • Used in tissue repairs
  • Used as part of integrative medicine in the
    better management of disease .
  • Nutrients / bioactive agents help the
    conventional drugs to work better
  • Used for normal reproductive performance
  • Used for maintenance of the immune system
  • Co-factors for several metabolic processes in
    the body.
  • Good nutrition maintains optimal health status
    ,prevents many diseases from occurring or the
    old ones emerging.

7
  • Nutrition intervention in HIV/AIDS
  • Nutrition intervention in HIV/AIDS is a neglected
    area , generally
  • Yet its beneficial effect in HIV/AIDS prevention,
    ,care and mitigation is well known This
    treatment aspect of HIV/AIDS is lacking in
    sub-Saharan Africa (SSA)

8
  • Beneficial effects of nutrition intervention in
    HIV/AIDS Evidence that nutrition intervention
    can reduce mother-to child HIV infection
    transmission .
  • Nutrition intervention delays HIV disease
    progression to full blown AIDS.
  • Nutrition intervention improves the quality of
    life of people living with HIV/AIDS.

9
  • Objectives of nutrition intervention
  • Optimize and maintain proper nutrition
  • Improve quality of life of the infected people
  • Prevent or reverse micronutrient deficiencies
  • Reverse the biochemical and immunological changes
    associated with HIV/AIDS .
  • Prevent or stabilize weight loss
  • Preserve muscle mass.
  • Optimize and maintain the immune system.

10
  • Prevent enteric infections (2/3 of the
  • immune system is in the GIT)
  • Promote recovery from infections
  • Promote response to medical treatment (both
    conventional drugs to treat opportunistic
    infections and ARVs to treat HIV infection)
  • Unfortunately , there is limited capacity for
    intensive nutrition support in resource
    constrained settings , such as occur in
    sub-Saharan (SSA)
  • Reversal of abnormalities in immunity and
    nutrition is possible in early HIV infection.

11
  • Nutritional support in HIV/AIDS
  • Great variation of nutritional requirements in
    HIV/AIDS patients
  • Different modes of feeding in HIV/AIDS patients
  • Dietary regime to provide RDA (all nutrients)
    except vitamins and minerals (3-4X)
  • Recommended diet for HIV patients is not
    different from that required for healthy
    individuals

12
  • Deficiencies of several micronutrients have been
    documented in HIV- infected people
  • In severe AIDS , incremental factors for some of
    the nutrients are
  • Selenium (3-8X), Zinc (7-15X), magnesium (1-2x),
    vitamins A (6X), vitamin B1 (25-50x) vitamin B2
    (25-50X) , Vitamin B6 (25-50x) , vitamin B9
    (2-3x) vitamin B12(5-10x)
  • Nutrient concentrates such as nutritional
    supplements meet the enormous nutrient
    requirements for HIV/AIDS.

13
  • HIV/AIDS is a highly stressful , wasting syndrome
  • Ordinary diets for healthy individuals may not
    meet the nutrient requirements in HIV/AIDS
  • Ordinary diets are sufficient in early stage of
    the disease.
  • Consumption of naturally grown organic foods may
    meet the nutrient requirements of the disease
    process.

14
  • HIV plate
  • An HIV plate has been contemplated for the
  • AIDS patients
  • It Constitutes
  • Protein 40 (20-40) Carbohydrates
    50 (50-70)
  • Fat 10 (5-10)
  • Vitamins minerals 3-4x RDA
  • Water 2-4L/24hrs
  • Hence a combination of carbohydrates (55)
    proteins(40) fat (5) may correct the
    nutritional wasting in HIV/AIDS

15
  • The effects of HIV infection and nutrition on
    each other and malnutrition and HIV disease
    progression

NUTRITION
HIV
AFFECTS
16
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17
  • Source Designed by C. Mugisha 2006
  • Key notes
  • Malnutrition is defined as involuntary weight
    loss gt10, weight lt 90 of ideal, lt 90 of body
    cell mass , lt 20 of body mass index (See WHO
    definition )
  • Malnutrition (macro and micro nutrient
    deficiencies) is common in HIV/AIDS disease.
  • Malnutrition in HIV/AIDS is associated with
    oxidative stress which depresses the immune
    system .
  • Malnutrition weakens the immune system and
    increases susceptibility to opportunistic
    infections.

18
Similarity of the effects of malnutrition and HIV
disease on immune system (Immunological changes
  • Malnutrition Immune system HIV-disease
  • CD4 T-lymphocyte number
  • CD8- (cytotoxic) T-lymphocyte number
  • Delayed cutaneous hypersensitivity
  • CD4/CD8 ratio
  • Serologic response after immunization
  • Bacterial killing capacity of phagocytes/
  • Polymorphs.

19
  • Source Designed by C. Mugisha , 2006
  • Key notes
  • The diagram shows similar immunological changes
    in primary malnutrition and HIV/AIDS.

20
  • Source Designed by defined as involuntary
    weight lossgt 10 weight lt 90 of ideal lt 90 of
    body all mass, 20 of body mass index (see WHO
    definition)
  • Malnutrition in HIV/IDs is associated with
    oxidative in HIV/IDS is associated with oxidative
    stress which depresses the immune system
  • Malnutrition weakens the immune system and
    increases susceptibility to opportunistic
    infections.

21
  • The vicious cycle of HIV pathogenesis

22
  • Source Designed by C. Mugisha , 2006
  • Key notes
  • The gastro intestinal tract (GIT) is one of the
    organs affected by HIV infection
  • GIT dysfunction is set in motion (diarrhoea,
    malabsorption , malnutrition)
  • Opportunistic infections proliferate
  • HIV disease progresses to full-blown AIDS
  • HIV infection is associated with enhanced
    oxidative stress (excess free radical production)

23
  • There is relative depletion of the bodys
    anti-oxidant forces.
  • Reduced food intake and poor nutrient
    absorption lead to weight loss, weakened immune
    system
  • The above processes hasten HIV disease
    progression to full blown AIDS.

24
  • The vicious cycle of malnutrition and HIV/AIDS

25
  • Source Adapted from the regional centre for
    quality of Health care and FANTA 2003
  • FANTA- Food and nutrition technical assistance
  • Key notes
  • The diagram shows the interacting factors in the
    vicious cycle of HIV infection, immune system
    suppression and nutritional status.

26
  • Effects of HIV/AIDS on nutrition
  • Loss of appetite
  • Decrease in the amount of food consumed
  • Impaired nutrient absorption (GIT enteropathy)
  • Alterations in body metabolism (cytokine
    mediation)
  • Defective enzyme system.

27
  • Changes in body metabolism (nutritional) in
    respect of HIV disease
  • HIV infection increases energy (10-15) and
    protein (50) requirements .
  • In severe AIDS, energy demands go up to 55 and
    protein requirements go up to 60, while fat
    requirements are about 5 (limit fat intake,
    because of fat malabsorption syndrome).
  • Infection increases demand for and the
    utilization of anti-oxidant vitamins (A,C,E, Beta
    carotene) and anti-oxidant micro- minerals
    (Zinc, selenium, copper , manganese, iron,
    magnesium )(3-4x)

28
  • Increased cytokine activity(IL-1, IL-6, TNF).
  • The net result is insufficient anti-oxidant
    status, leading to oxidative stress which
    depresses the immune system.
  • Increased HIV replication and rapid progression
    to full blown AIDS.

29
  • Mechanisms of weight loss and wasting in HIV/AIDS
  • Wasting is almost universal and a recognized sign
    in HIV/AIDS, both in adults and children
    (CDCWHO).
  • The wasting may be of slow or rapid progression
  • Several factors are responsible for wasting in
    HIV/AIDS
  • Reduced food in take (reduced appetite, nausea,
    vomiting).
  • Malabsorption (HIV gastroenteropathy).

30
  • increased nutrient loss (chronic diarrhea ).
  • Increased nutrient demands (highly stressful
    wasting syndrome)
  • Increased nutrient utilization (HIV is a wasting
    and stressful condition).
  • Increased nutrient utilization (HIV is a wasting
    and stressful condition).
  • Metabolic changes inflammatory, unbalanced
    cytokine response to HIV infection (IL-1, 1L-6,
    TNF, etc).

31
  • Pathogenesis of wasting in HIV infection
  • Alterations in oral intake weight loss
  • Loss of appetite /Nausea / vomiting
  • Decreased food intake
  • Food drug interactions (indirect-effect)
  • Elevated metabolic rate (e.g increased
  • cytokine activity (indirect effect)

32
  • Causes for altered food intake are
    multi-factorial
  • Oropharyngeal lesions
  • Oesophageal lesions
  • Psychosocial factors
  • Economic factors
  • Fatigue
  • Focal or diffuse neurological diseases
  • Anorexia due to medications (lt 500kcal intake
    /day)
  • Malabsorption/defective enzyme systems.
  • Systemic infection

33
  • Stool incontinence
  • Chronic diarrhoea
  • Conscious effort to avoid eating (anal
    incontinence )
  • The anorexia is thought to be medicated by
    inflammatory cytokines (IL-1, IL-6, TNF , etc)

34
  • Metabolic alterations
  • Marked cachexia in HIV/AIDS
  • Opportunistic infections, lymphomas /cancers
    compound the wasting state.
  • Weight loss may be rapid (7-11kg/week or 5 of
    body weight per month).
  • Metabolic rate is very high
  • Food intake is markedly diminished.
  • Extreme lethargy and weakness.
  • Rapid wasting is seen in the quadriceps and
    gluteus maximus muscles (skinny legs and flat
    butt) among other areas.

35
  • Hypertriglyceridemia (increased lipids in blood
    stream)
  • Adipose tissue atrophy
  • Decreased serum cholesterol concentrations.

36
  • Endocrine alterations in HIV infection include
  • Increased serum cortisol concentration
  • Loss of the cortisol normal diurnal periodicity
  • Low serum testosterone
  • Low dihydroepiandrosterone (DHEA)
  • Deficient endogenous anabolic activity, which may
    promote protein breakdown and hence weight loss.

37
  • Malabsorption / Chronic diarrhea
  • Diarrhoea is very common in HIV infection
  • It affects about 60 of HIV infected individuals
    in the United States of America at some point in
    the disease process and up to
  • A greater percentage of HIV infected individuals
    in the developing countries
  • Many opportunistic infections, depending on the
    geographical region, are responsible for some
    gastro intestinal pathologies.

38
  • The small intestinal epithelial cell damage leads
    to malabsorbption (The brush border with
    digestive enzymes is damaged).
  • Malabsorption of fats and bile acids / salts
    because of ileal dysfunction has been associated
    with chronic bacterial enteropathy caused by
    adherence of pathogenic strains of E. Coli to the
    brush border.
  • A role for HIV infection as a causative agent in
    malabsorption is uncertain.

39
  • Alterations in energy expenditure
  • Weight loss is a consequence of negative caloric
    balance
  • Normal nutritional status (NS) implies total
    energy intake (TEI) equals total energy
    expenditure (TEE). (NS TEI TEE)
  • TEE resting energy expenditure (REE) energy
    expenditure in activity (EEA) energy
    expenditure in digestion (EED).
  • EED is also known as thermal dynamic action of
    food (TDAF)

40
  • Effect of disease stage
  • The course of HIV infection can be subdivided
    into 3 stages Early, middle and late.
  • Early stage (Asymptomatic stage).
  • Early stage includes seropositivity without
    clinical or immunological evidence of deficiency.
  • Little evidence of HIV- associated nutritional
    problems at this time.
  • Give nutrition education (promotive, harmful)
  • Maintain normal body composition

41
  • The middle stage
  • Laboratory evidence of immune deficiency, but
    little clinical evidence of the disease.
  • Weight loss may occur may not be progressive
  • Variable fatigue
  • Oral (or vaginal) candidiasis may be present.
  • Herpetic lesions or aphthous ulcers in the mouth
    may become frequent.
  • Reduced body cell mass
  • Elevated basal metabolic rate is related to
    viraemia.
  • Weight loss is detectable due to productive HIV
    infection

42
  • Late stage
  • Clinical and laboratory evidence of immune
    deficiency.
  • Patients have frank AID or are undergoing active
    progression to AIDS.
  • Malnutrition occurs ,and may be severe and
    progressive.
  • Severe malnutrition may lead to death by
    inanition.
  • The pathogenesis of malnutrition in HIV/AIDS is
    multi- factorial e.g.

43
  • Defective nutrient intake
  • Defective nutrient absorption
  • Defective intermediary metabolism
  • Treat infections
  • Use therapeutic diets

44
  • Clinical consequences of malnutrition on HIV/AIDS
  • Malnutrition per se has adverse clinical
    consequences on any given condition for a
    patient.
  • Malnutrition in HIV infection is associated with
    increased morbidity and mortality.
  • Malnutrition in HIV / AIDS leads to weight loss
    which in turn predicts shortened survival.
  • The effect of weight loss upon mortality was
    independent of CD4 lymphocyte counts.

45
  • Weight loss was also associated with high risks
    of requiring hospitalization and being diagnosed
    with opportunistic infections. These effects were
    also independent of CD4 lymphocyte counts.
  • The timing of death from wasting in HIV/AIDS in
    related to the degree of body cell mass depletion
    rather than the specific cause of the wasting
    process.

46
  • HIV/AIDS AND FOOD SECURITY
  • Even if we could provide a plow and seeds to
    harvest every bit of land , there are not enough
    able bodied people to do the work (UNICEF
    senior programme officer Kimberly Gambie
    payne).
  • Food security has three (3) components
  • i) Supply side
  • - Food availability and stability
  • ii) Demand side
  • - Food accessibility and affordability
  • iii) Health side
  • - Food safety/ hygiene.

47
  • Food security
  • People at all times have physical , social
    economic access to
  • Sufficient , safe and nutrition food .
  • Meets dietary needs and food preferences
  • For an active and healthy life .

48
  • In Uganda, 0.9 of the GDP annually is lost due
    to HIV/AIDS pandemic.
  • The agricultural labour force loss is about
    14Uganda, in Tanzania, it is about 13, while
    in Kenya, it is about 12.
  • Deaths due to HIV/AIDS increase annually (UN
    estimates)
  • Excess deaths in females out number those in
    males.

49
  • Assessment of HOV/AIDS patients Welcome
    classification (WL/A)
  • Gomez Classification (WL/A)
  • Water low classification (WL/A) (WL/A. W/H , 2-5
    core)
  • Mid-upper aim circumference
  • Body mass index

50
  • The food pyramid

51
  • Source US department of agriculture and
  • health and social services.
  • Key notes
  • The food pyramid was provided by the education
    department of the national livestock and meat
    board.
  • The food guide is commonly used to evaluate the
    dietary status of individuals and to educate
    patients about food choices.

52
  • The principles of diet design
  • These are
  • Nutrient adequacy and safety
  • Nutrient balance
  • Nutrient density
  • Energy/ kilocalorie control
  • Nutrient moderation
  • Nutrient variety
  • 13, Identification of available ,accessible ,
  • healthy foods.

53
  • Dietary management of HIV/AIDS
  • Malnutrition in HIV/AIDS is a multifaceted
    problem requiring multiple interventions.
  • The multiple interventions may be short- term
    (1-2 years), medium term (2-5 years), and
    long-term (gt5 years), applied simultaneously to
    break the vicious cycle of malnutrition.
  • The major components of the vicious cycle that
    need to be addressed are
  • i) Depressed immunity
  • ii) Infections and infestations (opportunistic)

54
  • Malnutrition
  • In this presentation, emphasis will be put on the
    prevention and management of malnutrition in
    HIV/AIDS.
  • HIV/AIDS patients should be assessed and
    classified for malnutrition, the same way as
    other malnourished patients (See previous
    anthropometric measurements).
  • If found severely malnourished, they should be
    admitted to the therapeutic feeding centre (TFC)
    and managed for nutritional, medical and
    psychosocial complications, as well as daily care.

55
  • Referral for continuous follow-up and medical
    care in health facilities or specialized
    infectious disease centres (IDC), as well as
    supplementary feeding centres (SFC) should be
    observed.
  • Referral to agencies that may offer assistance
    and continued care, such as TASO, should be made.
  • The HIV/AIDS patients recovery takes longer than
    the matched non- HIV infected malnourished
    patient.

56
  • The therapeutic feeding centre (TFC) should not
    be involved in the chronic care of HIV /AIDS
    patients.
  • Clinical status rather than official discharge
    protocol should be used for discharge.
  • Physical and emotional stimulation for cases
    resulting from prolonged state of illness is
    important .
  • Recommended micronutrients in normal and HIV
    positive child- bearing age women (15-49 years)

57
  • Recommended micronutrients in normal and HIV
    Positive child bearing age women (15-49 years)

58
  • Source Compiled by C. Mugisha, 2006
  • Key Notes
  • The table shows the recommended micronutrients in
    normal and HIV positive child being age women
    (15-49 years) in SSA and USA.
  • It also shows the requirements of micronutrients
    in HIV infection and the incremental factors of
    the quoted nutrients for sub- Saharan Africa

59
  • Reference nutrient intakes for protein
  • Age Reference Nutrient Intake a(g/day)
  • Children
  • 0-3 months 12.5b
  • 4-6 months 12.7
  • 7-9 months 13.7
  • 10-12 months 14.9
  • Years 14.5
  • Years 28.3
  • MALES
  • 11-14 years 42.1
  • 15-18 years 55.2
  • 19-50 years 55.5
  • 50 years 53.3
  • FEMALES
  • 11-14 years 41.2
  • 15-18 years 45.0
  • 19-50 years 45.0
  • 50 years 46.5

60
  • Key
  • Source Smith R. and W.P.T .James (eds). Oxford
    Text book of medicine (Nutrition). 3rd edition,
    vol.1,1996.
  • a These figures, based on egg and milk protein,
    assume complete (100) protein digestibility.
  • b No values for infants 0-3 months are given by
    WHO . The recommended nutrient intake (RNI) is
    calculated from the recommendations of COMA.
  • c To be added to adult requirements through all
    stages of pregnancy and lactation.
  • d- Based on protein providing 14.7 percent of
    estimated average requirements (EAR) for energy.

61
  • Reference nutrient intakes for vitamins.

62
  • Source Smith , R, and W.P.T. James (eds).
    Oxford textbook of medicine (nutrition ), 3rd
    edition, Vol, 1996.
  • Key notes
  • No increment
  • After 65 years, the RNI is 10mg /day for men and
    women .
  • For last trimester only.
  • Based on protein providing 14.7 percent of
    estimated average requirements. (EAR) for energy.

63
  • Reference nutrient intakes for minerals

64
  • Source Smith R. and W.P.T .James (eds). Oxford
  • Text book of medicine
  • (Nutrition). 3rd edition, vol.1,1996
  • Key notes
  • a - No increment
  • b - Phosphorus RNI is set equal to calcium in
    molar terms
  • c - 1 immol sodium 23mg
  • d - 1 mmol potassium 39 mg
  • e - Corresponds to sodium 1 mmol 35.5mg
  • f - Insufficient for women with high menstrual
    losses where the most practical way of meeting
    iron requirements is to take iron supplements or
    iron fortified foods.

65
  • Goals of nutrition actions
  • Some approaches
  • To prevent weight loss.
  • Promote adequate energy , protein and
    micronutrients intake.
  • Individualize the meal plan and modify to match
    the medication regime or health attentions .
  • Advise on lifestyles that are promotive, harmful
    or neutral to health.
  • To improve on the body composition
  • Promote regular exercise to preserve, and build
    muscle mass.

66
  • To improve immunity and prevent infections
  • Promote nutritional adequacy to meet the nutrient
    demands for optimal physiological functions.
  • Promote food safety/ hygiene (safe kitchen
    behaviour)
  • As this may be a source of opportunistic
    infections.
  • Promote the use of ARVs and other conventional
    medications to reduce the viral load and treat
    opportunistic infections.

67
  • Increase micronutrient intake
  • Promote strategies to increase vitamin and micro-
    mineral intake (Increased consumption of fruits
    and vegetables)
  • Micronutrients serve as co- factors for the body
    metabolism and the promotion of the immune system.

68
  • Food based approaches
  • Include local vegetables, fruits or vitamin /
    mineral enriched or fortified local products (e.g
    maize, cereals , wheat or soya flour).
  • The foods should be affordable
  • The food based approach has no major side
    effects.
  • Use nutrient supplements (mainly body nourishes,
    detoxifiers/ cleansers, immune boosters )
  • Multi-micronutrients supplements are better
    utilized than single nutrients .

69
  • Promote the use of ARVs and
  • conventional drugs
  • Reduce the viral load
  • - Treat opportunistic infections
  • - Promote immunity

70
  • Dietary management of symptoms in
  • HIV/AIDS.
  • Aims / Objectives
  • To enable greater food intake
  • Contribute to increased comfort
  • Compensate for nutrient losses
  • Prevent dehydration.
  • Complement and strengthen medical treatment
  • Reduce severity of symptoms

71
  • Examples of common symptoms in
  • HIV/AIDS and their dietary management
  • Anorexia / vomiting
  • Eat small amounts of food frequently
  • Eat energy dense food (High nutrient density
    foods).

72
  • Oral thrush / oral candidiasis.
  • Eat soft, mashed food at room temperature or body
    temperature.
  • Avoid spices
  • Avoid cold foods
  • Limit sugar / sucrose use.
  • Constipation.
  • Eat more high fibre diet / food
  • Drink plenty of fluids /water (2-4L/ 24hrs ).

73
  • Heartburn / Dyspepsia / Bloating
  • Eat small and frequent meals
  • Take milk regularly
  • Avoid gas forming foods, such as beans
  • Eat dinner about 3 hours before going to bed
  • Diarrhoea
  • Drinking lots of fluids / water (2-4 L / 24 hrs)
  • Eat energy and nutrient dense foods

74
  • Nausea
  • Eat small frequent meals
  • Avoid lying down immediately after food
  • Rest between meals
  • Fever
  • Drink plenty of fluids (2-4L/ 24 hrs)
  • Eat / drink a variety of soups
  • Eat energy and nutrient dense foods

75
  • Anaemia (Iron deficiency)
  • Eat iron fortified/ rich foods (e.g animal
    products) , green leafy vegetables
  • Take nutritional supplements with iron to correct
    iron deficiency anaemia.
  • Fatigue / lassitude lethargy.
  • Moderate, regular physical activity increases
    energy expenditure, stimulates appetite,
    preserves and builds muscle / lean body mass).

76
  • Infections, infestations (opportunistic).
  • Preventing food and water borne infections /
    infestations reduces the risk of diarrhea (a
    common contributing factor to weight loss),
    Malnutrition and HIV disease progression to full
    blown AIDS.
  • Antiretroviral therapy (ART) can help improve the
    quality of life, and patients given comprehensive
    nutrition in addition to ARVs usually do better
    than those on either mode of management.

77
(No Transcript)
78
Drug food interactions in HIV infected patients
79
  • Special nutrition needs related to HIV/AIDS and
    pregnancy and lactation.
  • The goals of nutrition management include
  • Prevention or mitigation of factors associated
    with the risk of malnutrition.
  • Preserve body composition
  • Use of balanced , locally available , natural ,
    organic foods
  • Food pyramid should serve as a nutritional
    guide

80
  • Concurrent use of ARVs plus other conventional
    drugs
  • To correct nutrition related metabolic changes
    caused by viral infection.
  • HIV- infected pregnant and lactating women have
    poorer indices than non-infected women
  • Malnutrition in HIV/AIDS in multifaceted ,
    requiring multiple interventions
  • Cachexia (severe wasting) associated with
    HIV/AIDS responds well to ARV/ART

81
  • Use of ARVs, conventional drugs , nutrition,
    counseling, social support etc have changed the
    out look for many HIV-infected persons ,
    especially nutritional status
  • Ensure adequate nutrient intake.

82
  • Special nutrition needs related to HIV/AIDS and
    children
  • The management of HIV exposed and HIV
    infected children who are also malnourished
    include
  • Prevention or mitigation of factors associated
    with the risk of malnutrition.
  • Appropriate breast feeding practices.
  • Nutrition supplementation
  • Preserve body composition
  • Use of breast milk (heated ) and breast milk
    substitutes.
  • Malnutrition underlies 60 of all infectious
    diseases morbidity

83
  • Factors that increase the risk of under
  • nutrition in childhood.
  • Low birth weight (LBW)
  • Inappropriate feeding practices
  • Repeated infections
  • Inadequate time set aside for infant and children
    and child feeding care
  • Altered body metabolism
  • Inadequate access to ARVs/ART (HAART)

84
  • Infant feeding practices / guidelines
  • Breast feeding is the primary guarantee for child
    survival in resource poor settings.
  • Unfortunately , breast feeding by HIV- infected
    women significantly increases the incidence of
    HIV- infection amongst breast-fed infants,
  • Lactating mothers with HIV infection pose an
    additional risk of transmitting the infection
    above the risk during pregnancy and delivery of
    about 15 for HIV exposed babies who are
    breast fed up to six months and about 20 for
    babies who breastfeed into the second years of
    life.

85
  • Women who are newly infected during pregnancy or
    lactation have a much higher likelihood of
    transmitting HIV infection to their infants.
  • The risk of transmission through the breast milk
    among women with recent infection is about 25.
  • Babies continue to be at risk of HIV infection as
    long as they are exposed to HIV- contaminated
    breast milk.
  • Breast - feeding problems (Such as cracked and
    sore nipples, mastitis, and breast abscesses)
    significantly increase the risk of transmitting
    HIV by breast milk.
  • Hence suitable replacements for breast milk.

86
  • Such breast milk substitutes include -
  • Commercial infant formula
  • Home prepared formula (eg soya milk )
  • Modified animal milks.
  • Mixed feeding may be more risky for HIV
    transmission than exclusive breast feeding,
    possibly because of the damage to the epithelial
    integrity of the intestine by food particles,
    which may facilitate the virus entry into the
    blood stream.

87
  • Infant feeding during period 0 to 6 months.
  • There is need to minimize the risk of HIV
    transmission to infants in the critical exclusive
    breast feeding period 0-4/6 months.
  • One way is to boil the expressed breast- milk in
    water for about 20 minutes and then feed the baby.

88
  • There is also a necessity to avoid increasing
    their risk of morbidity and mortality from other
    causes. Therefore when replacement feeding is
    acceptable, feasible, affordable, sustainable and
    safe (FAASS), avoidance of all breast- feeding by
    HIV infected mothers is recommended.
  • Otherwise, exclusive breast feeding is
    recommended during the first months of life, and
    then should be discontinued as soon as feasible
    (WHO/UNICEF/UNAIDS).

89
  • Safe- breast feeding
  • If adequate replacement feeding is not possible
  • Two strategies to reduce the risk of breast milk
    transmission of HIV
  • Exclusive breast feeding with early cessation
  • Heat treatment of breast milk
  • The strategies allow an infant to derive the
    benefits of breast feeding during the most
    critical period .

90
  • Artificial feeding in environments with poor
    hygienic conditions in the first few months of
    life can be tragic.
  • Reduces the risk of HIV transmission by reducing
    the length of time ,the infant is exposed to HIV
    through the breast milk.

91
  • Replacement feeding
  • Stop breast-feeding as soon as mother is able
    to prepare and give her infant adequate and safe
    replacement feeding.
  • Family conditions can determine when mother may
    stop breast feeding and start replacement
    feeding .
  • Early cessation of breast-feeding is advisable
    if an HIV positive mother develops AIDS
  • Socio-cultural reasons may bar woman from breast
    feeding.
  • Replacement feeding includes feeding with a
    commercial or home prepared formula.
  • 0-6 months give milk in some form.

92
  • Commercial infant formula (CIF).
  • A baby who is not breastfed will need about
    150mls of milk per kg body weight per day.
  • CIF is an option to breast feeding for an HIV
    positive woman
  • Should be feasible and affordable by the family
    for at least 6 months (ie when the family has
    reliable access to sufficient formula for at
    least 6 months).
  • Feeding an infant with the commercial formula for
    6 months requires 40x 500g tins (or 44 x 450 g
    tins ) of the formula .

93
  • The family should have the resources, water,
    fuel, utensils, skills and time.
  • The time is to enable the mother prepare the
    formula correctly and hygienically.

94
  • Home prepared formula (HPF)
  • (HPF) is a reasonable option for an HIV- positive
    lactating woman.
  • May be used under following circumstances
  • CIF is not available
  • CIF is too expensive for family to buy and
    prepare
  • Reliable supply of animal or other milk
  • Family can make modifications accurately.

95
  • Attention paid to hygiene , correct mixing ,
    feeding methods.
  • Replacement feeding is often a new way for a
    mother t feed her baby.
  • It should not be assumed that the mother knows
    how to do it.

96
  • Infant feeding after 6 months
  • Introduce complementary foods
  • Breast fed and replacement fed, complementary
    foods introduced at 6 months.
  • Duration of mixed feeding should be limited .
  • Avoid undue traumatic effects, abrupt cessation
    of breastfeeding can have on baby .
  • Milk should continue to be an important component
    of diet.
  • It should provide 50 of nutritional
    requirements between 6-12months.

97
  • Milk may provide up to 33 of nutritional
    requirements between 12-24months.
  • Family foods given 3 x per day for 6-9month
  • Family foods given 4x per day for 9-12 month
  • Family foods given 5 x per day for 12months
  • I
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