Nutrition and HIV

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Nutrition and HIV

• Nigel C Rollins
• Maternal and Child Health
• University of KwaZulu-Natal

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(No Transcript)
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Lancet 2003 362 1234-37
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A new variant famine?

• Secondary effects of the AIDS epidemic on food
  security, famine and nutrition could be as great
  as the primary effects
• Present southern Africa drought and food crisis
  compounds AIDS epidemic
• Historical coping strategies are in danger of
  collapsing.
• Present food crisis more intractable
• High degree of vulnerability in areas not
  affected by drought
• Household impoverishment has occurred more
  rapidly
• Despite early rains in early 2003, high levels of
  vulnerability persist

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Nutrition and HIV Sub-Saharan Africa vs. Europe
/ N. America

• At risk populations for HIV/AIDS also at high
  risk of food insufficiency
• Poor quality of food as well as limited quantity
  limited choices
• Higher burden of infectious diseases and
  therefore need for effective antioxidant systems
• Chronic malnutrition in the general population
  introduces complex issues of equity and
  distribution

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• Adults and children with HIV infection have
  increased energy needs from the time they first
  become infected these need to be met in ways
  that are appropriate and adequate
• Monitoring weight is a very useful way of
  following disease progression in an individual
• HIV infected adults and children are susceptible
  to misinformation and commercial exploitation
  know your facts

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HIV-associated wasting
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Growth in HIV-infected children sub-Saharan
Africa experience

• Growth is severely affected in HIV-infected
  children
• Growth faltering is common and occurs early in
  life.
• Indus. countries gt50 by 5yr vs. SSA 50 by 1
  yr
• Decreases in length- and wt- for-age observed by
  3 mos of age (Bobat 1998, Bobat 2001)
• While both wt and length are severely affected, a
  disproportionate effect on wt (wasting) is
  reported in some cohorts by age 1 year

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Growth faltering has marked effect on survival

• Poor growth strongly and independently associated
  with poor survival in US, European, African, and
  HIV haemophilia populations.
• In US children on antiretrovirals, poor growth is
  an independent risk factor for death
  (McKinney1994, Benjamin 2003, Carey 1998).
• Ugandan infants with low wt. had a 5-fold
  increase in risk of death by age 25 mos. (Berhane
  1997).

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Body Mass Index at time of HIV Diagnosis
BMI lt18 is a significant independent predictor of
mortality and is comparable to CD4 count.
J Acquir Immune Defic Syndr, 37(2) 2004
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Body composition abnormalities HIV-infected
children

• HIV-infected children have disproportionate
  decreases of lean body mass with preservation of
  body fat (Miller 1993, Arpadi 1998).
• Reduced lean body mass is detectable prior to
  decelerations in linear growth.

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Diarrhoea has marked impact on growth

• Diarrhoea reported 90 of HIV-infected children
• Chronic diarrhoea 6 times more likely to develop
  in HIV-infected vs. uninfected children (Keusch
  1992).
• Persistent diarrhoea associated with 11-fold
  increased risk of death (Thea 1990).
• The mean growth for HIV-infected infants with gt1
  episodes of diarrhoea / yr was 1.4 cm/yr less
  than infants with lt1 episode (Villamor 2004).

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12-month growth velocity(cm/yr) vs HIV viral load
(HIV RNA copies/ml) performed in HIV-infected
children (n42)
Growth velocity is inversely related to viral load

• Growth velocity and FFM are inversely related to
  level of viral replication
• Viral replication remains a negative determinant
  of growth rate even after adjusting for food
  intake.

Arpadi 2000
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Potentially modifiable factors involved in
HIV-associated growth abnormalities

• Dietary deficiencies
• prevention and treatment
• Diarrhoeal illnesses
• prevention, detection, and nutritional management
  
• HIV replication and immune suppression
• use of anti-retroviral medications

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Growth, body composition and dietary intake?

• In contrast to simple malnutrition, pre-HAART
  studies found enteral supplements improved wt and
  fat stores but not ht or lean body mass (Miller
  1995, Henderson 1994).

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Viral suppression improves growth and body
composition abnormalities

• Large studies detect improvements in growth
  (wtgtht) attributable to protease inhibitor use
  (Buchacz 2001, European Collaborative 2003)
• Improvements in gut absorption reported (Canani
  1999)
• Dietary intake is stable with ART (Miller 2001).
  

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WHO Technical Review Growth abnormalities in
HIV-infected children

• HIV impairs the growth of children early in life,
  especially height growth. Often occurs before the
  onset of OIs /other symptoms. Growth failure
  associated with increased risk of death.
• The exact mechanisms of wasting are complex but
  insufficient food intake and diarrhoea are major
  causes of poor growth, especially in
  resource-poor countries
• Cotrimoxazole improves growth and survival
• ART, when clinically indicated, improves weight,
  growth and development of infected children

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WHO Technical Review Energy and protein needs

• Energy needs increase by about 10 in adults and
  children from the time of infection
• During and after severe illnesses, these needs
  might increase by a further 20-30. In children
  this may be up to 150.
• No evidence for increased protein requirements
  other than in a balanced diet i.e. 12-15 of the
  total energy intake
• Anorexia and poor dietary intake are important
  causes of weight loss
• Improving the diet alone, though, may not result
  in weight recovery and improvement in clinical
  status

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Micronutrients and HIV infection
Henrik Friis
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Does micronutrient status / intake affect HIV
infection?

• Increased micronutrient status / intake may
  affect
• Transmission of HIV infection
• mother-to-child transmissions
• sexual transmission
• Infectiousness and susceptibility
• Progression of HIV infection
• HIV load, CD4 counts, AIDS, death
• Morbidity from other infections
• Drug acceptability, efficiency, safety

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Multiple micronutrients and HIV
infectionIntervention trial

• Randomised trial in Thailand (Jiamton S, 2003)
• 481 HIV adults
• Multimicronutrient or placebo for 48 wks
• minerals zinc 30 mg, iron 10 mg, selenium 0.4
  mg, copper 3 mg, iodine 0.3 mg, chromium 0.15 mg,
  manganese 8 mg, magnesium 80 mg
• vitamins A, B-complex, C, D, E, K
• Mortality reduced
• RR 0.53 (95 CI 0.22, 1.25)
• RR 0.26 (95 CI 0.07, 0.97) among those with
  CD4lt100
• No effects on HIV load and CD4 counts

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NEJM 200435123-32
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vs. RNI (daily intake which meets nutrient
requirement for 97.5 apparently healthy
individuals in an age and sex-specific population)
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• 299 progressed to WHO stage 4 or died of
  AIDS-related causes
• 67 of 271 (24.7) MVS
• 70 of 268 (26.1) MVS Vit A
• 79 of 272 (29.0) Vit A only
• 83 of 267 (31.1) placebo
• MVS vs. placebo
• RR 0.71 95CI 0.51-0.98 P0.04
• reduced progression to stages 3 or 4
• MVS group cf. placebo - higher CD4 and CD8
  counts and reduced VL
• Adding Vit A reduced the benefit

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? Generalisability for policy

• Single study, urban
• 100 deaths excluded
• Possible misclassifications
• Why not an intention to treat analysis?
• Background maternal mortality 700/100,000!
• Mixed staging criteria
• Unusual composition based on beneficial effects
  reported in observational studies. ?Nutriceutical
  effect
• No HIV uninfected comparison mortality and
  pregnancy outcomes may be true for all women with
  borderline micronutrient deficiency
• Are data true for HIV-infected men as well do
  repeat study in men

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Neither zinc nor MMN had significant effects on
culture conversion, but MMN supplementation
increased weight gain in TB patients
(independent from culture conversion rates)
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WHO Technical Review Micronutrients requirements

• HIV-infected adults and children frequently have
  low levels of micronutrients i.e. low body status
• Micronutrient intakes at RDA need to be assured
  in HIV-infected adults and children through
  consumption of diversified diets, fortified foods
  and micronutrient supplements as needed
• WHO recommendations on vitamin A, zinc, iron,
  folate and multiple micronutrients remain the
  same
• Vitamin A supplements reduce diarrhoeal morbidity
  and mortality especially in young children

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WHO Technical Review Micronutrients and HIV -ctd

• Micronutrients are not an alternative to
  comprehensive HIV treatment including ARV therapy
• Studies have shown that some micronutrient
  supplements may prevent HIV disease progression
  and adverse pregnancy outcomes. Additional
  research is urgently required

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Either or

• Idealogical - optimising nutrition does not
  eradicate HIV
• Financial gain
• Fear that ARVs may be displaced as the focus for
  efforts 3x5
• Nutrition seen as a soft science and the data is
  not substantial and therefore not worthy

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WHO Technical Review Nutrition and
Antiretroviral therapy

• The benefits of ART are fully recognised but to
  achieve the full benefits adequake dietary intake
  is needed
• Dietary and nutritional assessment is an
  essential part of comprehensive HIV care both
  before and during ART
• Long term complications can occur with ART but
  the benefits outweight the potential harm
• CVS, diabetes, bone
• Little research has been conducted to fully
  understand the relationship between nutrition and
  ART e.g.
• Pharmacokinetics in the severely malnourished
• Potential benefit regarding adherence
• Interactions with herbal treatments and other
  therapies
• Impact of nutritional status on the development
  of longer term ARV related complications such as
  lipodystrophy and bone problems

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• Adults and children with HIV infection have
  increased energy needs from the time they first
  become infected these need to be met in ways
  that are appropriate and adequate
• Monitoring weight is a very useful way of
  following disease progression in an individual
• HIV infected adults and children are susceptible
  to misinformation and commercial exploitation
  know your facts

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Nutritional assessment

• Food and Nutrition History
• 24h dietary recall inclusive of determination of
  food access
• Anthropometric measurement
• Yearly height, weight, BMI, WHR, consider MUAC
  and skinfolds
• Biochemical Assessment
• Yearly fasting lipids, glucose and with change in
  ARV, yearly hemoglobin consider OGT in patients
  with IGT
• Nutrition focused medical history and exam
• Obtain weight and growth history at each visit