MNT FOR HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE

Noraishah Mohamed Nor

Dept Nutrition Sc

IIUM

Definitions

HIVHuman Immunodeficiency Virus – a retrovirus

that targets the CD4 T helper immune cells

AIDSAcquired Immunodeficiency Syndrome – the

final stage of HIV infectionThe result of infection with HIV is a inability of

the body to defend itself against other invaders leading to opportunistic infections

IntroductionGlobal Sub-Saharan Africa

People LivingWith HIV/ AIDS

(2005)

40.3 million 25.8 million*57% women

New HIV Infections (2005)

4.9 million

(14,000 people infected everyday)

3.2 million(70%)

AIDS Related Deaths (2005)

3.1 million 2.4 million

Statistic in M’sia

YEARHIV INFECTION AIDS CASES AIDS DEATH

Male Female TOTAL Male Female TOTAL Male Female TOTAL

1986 3 0 3 1 0 1 1 0 1

1987 2 0 2 0 0 0 0 0 0

1988 7 2 9 2 0 2 2 0 2

1989 197 3 200 2 0 2 1 0 1

1990 769 9 778 18 0 18 10 0 10

1991 1741 53 1794 58 2 60 10 9 19

1992 2443 69 2512 70 3 73 44 2 46

1993 2441 66 2507 64 7 71 50 5 55

1994 3289 104 3393 98 7 105 74 6 80

1995 4037 161 4198 218 15 233 150 15 165

1996 4406 191 4597 327 20 347 259 12 271

1997 3727 197 3924 538 30 568 449 24 473

1998 4327 297 4624 818 57 875 655 34 689

1999 4312 380 4692 1114 86 1200 824 50 874

2000 4626 481 5107 1071 97 1168 825 57 882

2001 5472 466 5938 1188 114 1302 900 75 975

2002 6349 629 6978 1068 125 1193 823 64 887

2003 6083 673 6754 939 137 1076 633 67 700

2004 5731 696 6427 1002 146 1148 951 114 1065

2005 5383 737 6120 1044 177 1221 882 102 984

2006 4955 875 5830 1620 222 1842 896 80 976

2007 3804 745 4549 937 193 1130 1048 131 1179

2008 2988 704 3692 795 146 941 786 114 900

TOTAL 77,092 7,538 84,630 12,992 1,548 14,576 10,273 961 11,234

HIV/AIDS Classification

HIV transmission and risk factors Transmission of HIV

Fluids commonly associated with transmission of HIV○ Vaginal fluids○ Semen○ Blood and blood components○ Breast milk

Behavioral risk factors○ Sexual intercourse whether vaginal, anal or oral

Number of sexual partners Intercourse with HIV infected Unprotected sex( lack of use of barrier precautions) Presence of STI (sexually transmitted infection) Influence of alcohol and other substances that impairs decision

making

○Exposure to blood and blood productsIV drug usersImproperly screened blood and

blood products○Congenital exposure

Exposure in pregnancy, labour and breast feeding

Pathophysiology

Acute HIV infection Due to initial infection and dissemination through out the

body and occurs 1-4 weeks after exposure

Common symptoms; Headache, fever, rash, sorethroat, tiredness, muscle pain, enlarged lymph glands. Usually <14 days but may be weeks or months. Non specific and could easily pass for common viral infections

Others; Nausea, vomiting, diarrhea, weight loss and acute psychological problems like irritability and confusion

Amount of virus in blood and genital secretions is so high. This is when most people are contagious. Occurs in 70 % of individuals

Seroconversion Body takes a few days to weeks to recognize a foreign

substance like a virus

Once substance is recognized, body produces antibodies that attack it

For HIV, 6-12 weeks after the virus has entered the body, antibodies are in sufficient quantities to be detected by the usual tests

>95% people have positive tests by 3 months while >99% of people have positive tests by 6 months

In most infections once antibodies and other protective cells appear, organisms are eliminated but not so with HIV

Asymptomatic HIV infection For several years after one is HIV antibody test

positive, People with HIV infection feel good. No clinical signs or symptoms

Person unaware of HIV infection unless tested

About 70-80% of people who are presently infected with HIV are in this asymptomatic phase

HIV continues reproducing every day making new viruses and destroying body’s defenses.

The body continues to produce new CD4s to offset the loss

Virus in the blood remain low and constant for many years

Eventually the body can’t quite keep up and with time progressive depletion of CD4 occur

The duration of this stage depends on how effective the body’s defenses were able to control the initial infection and therefore the amount of virus in blood(8-10 years)

Period is longer the earlier the age at time of initial infection

Symptomatic HIV disease Early symptomatic HIV disease

Declining CD4 Increasing virus in blood Symptoms include Fever, unexplained weight loss, recurrent

diarrhea, headache, tiredness and skin problems

Late symptomatic HIV disease (AIDS) Defense system is sufficiently compromised, the patient is

unable to control other infections leading to opportunistic infections and cancers

Without treatment the patient on average dies within 1-3 years Signs and symptoms typically parallels laboratory testing of CD4

counts Individuals could have very low CD4 without symptoms Risk of death from HIV infection with CD4 counts above 200 is

low

Progression to AIDS Typical progressors: 8-10 years asymptomatic

HIV before developing AIDSFall in viremia following acute infection

Rapid progressorsDevelop AIDS in 2-3 years following initial infectionHigh viral load during acute infection and levels do not

fall to those of typical progressors

Non progressors “long survivors”Relatively stable immune function for more that 10

years. Stable CD4Low viral burden

Factors influencing the time course to progression to AIDS

Acute infection is symptomatic Viral strain Higher viral “set point” Older age at sero conversion Opportunistic infection or neoplasm

present In Mother to child, signs of infection at

<3months

Clinical staging based on Natural history WHO staging into IV stages:

Stage I: Asymptomatic and has normal activityStage II: Symptomatic with weight loss, minor

skin problems, Herpes zoosterStage III: unexplained chronic diarrhea,

unexplained prolonged fever, PTB; Usually bed ridden < 50% of the day during last month

Stage IV: Opportunistic infection eg PCP, Cryptococcal meningitis, Toxoplasma infection of brain etc. Usually bed ridden > 50% of the day during last month

Diagnosis of HIV/AIDS Screening Tests licensed by the FDA

Test serum or plasma with high sensitivity to HIV type 1 (HIV-1) antibodies○ Enzyme-Linked Immunoabsorbent Assay (ELISA)

Confirmatory test○ ELISA, Enzyme Immunoassay (EIA), Western

blot, modified Western blot, indirect immunoflourescent antibody assay (FIA), and line immunoassay (LIA)

Combination ELISA testing○ Both antigen and antibodies○ Earlier diagnosis

Treatment Antiretroviral Therapies (ART)

Nucleoside reverse transcriptase inhibitors Nonnucleoside reverse transcriptase inhibitors Protease inhibitors Fusion inhibitors

Highly active retroviral therapy (HAART) Introduced in 1996 Combinations of ART medications (3 or more)

Aimed at interrupting viral life cycle and decreasing viral load Goal: < 50 copies/mL

Only prolong life and suppress symptoms, no cure currently exists

HIV/AIDS Related Clinical Complications Neuropathy

Antiretroviral (ARV) therapies Dementia

HIV infection, other infections, nutrient deficiencies

Pulmonary disordersHIV infection – low CD4 count

Cardiac ManifestationsInflammation process, infections, ARV

medication

Hepatic DisordersOpportunistic infection, anti-HIV treatment toxicity

AnemiasChronic HIV, hormonal alterations, infections,

ARV medications Renal Failure

ARV medications, infection○ HIV-associated nephropathy, tubular necrosis,

nephrolithiasis (kidney stones)

Role of Dietitian in HIV/AIDS Care

Monitor caloric intake Document nutritional adequacy Recommend methods for increasing

intake Education on proper diet and food safety Monitor nutrition abnormalities from

treatment Make recommendations to the rest of

the team in relation to nutrition

Nutrition Complications Malnutrition

MalabsorptionHypermetabolismDiminished intake

○ Dysphagia – mouth lesions○ Odynophagia – lesions to esophagus○ Dygeusia ○ Diarrhea – intestinal dysfunction due to pathogen○ Anorexia – neuropsychiatric, endocrinologic, or gastrointestinal○ Early satiety ○ Nausea and vomiting – side effect of medication○ Fever – opportunistic infections○ Fatigue – lean body mass depletion○ Apathy ○ Depression

Malnutrition leads to:MalabsorptionComplications with treatment regimensDecreased immune functionOrgan dysfunctionMicronutrient deficienciesWeight Loss – AIDS Wasting

A well-nourished HIV positive person with a

controlled viral load is more likely to be able to withstand the effects of HIV infection

Malabsorption:Most common – fat malabsorptionAssociated with:

○ Starvation-style malnutrition○ Villous atrophy○ Intestinal cell maturation defects○ Increased gut permeability○ Autonomic neuropathy○ Gastrointestinal pathogens

Nutrition - Treatment Interaction

Efficacy of treatment dependent on nutritional status maintenance and vice versaLow nutrition status drug efficacy:

○ Reduces drug absorption ○ Reduces activation and elimination of most drugs

Treatment nutrition status○ Reduce muscular protein synthesis ○ Diarrhea○ Nausea/Vomiting○ Appetite Loss

Altered immune function Leads to:

HypermetabolismOpportunistic infections

○ Candidiasis○ Cytomegalovirus○ Hepatitis C○ Herpes Simplex○ Mycobacterium Avium Complex (MAC)○ P. Jeroveci (PCP)○ Many more

Organ Dysfunction

Liver Lungs Pancreas Heart Small intestine

Micronutrient Deficiencies Caused by decreased absorption and

metabolism of nutrients and accelerated turnoverMost common:

○ Vitamin A○ Vitamin E○ Vitamin B12○ Selenium○ Zinc

Others documented:

Vitamin B6 Vitamin D Folate Carotenoids Riboflavin Copper

Weight Loss – AIDS Wasting AIDS Wasting: “involuntary loss of greater

than 10% of baseline body weight, accompanied by either chronic diarrhea (at least two loose stools per day for greater than 30 days) or chronic weakness and fever for 30 days or longer In the absence of concurrent illness or conditions” – CDC 1987Recommended revisions:

○ Time frames for weight loss○ Inclusion of body composition alterations ○ Guidelines for determining competing diagnoses

Caused by:Reduced food intakeMalabsorptionAbnormal nutrient utilization and metabolismOxidative stressHormonal abnormalitiesHAART treatmentPsychosocial difficulties

More important than weight loss is body composition alterationsDecreased Body Cell Mass (BCM)– metabolically

active, cellular component of the body, which makes up lean body mass

A loss of body cell mass of 54% is likely to result in death in HIV-infected patients regardless of the presence or absence of infectious complications.

HAART in AIDS Wasting Body composition changes despite weight

maintenanceLean tissue wastingLipodystrophy syndrome –

abnormal fat distribution○ Fat accumulates:

AbdomenDorsocervical – “buffalo lumps”Breast areas

○ Subcutaneous fat loss:LimbsFaceUpper trunk

Nutrition Intervention

Goals:Preserve body cell massProvide adequate amounts of all nutrients for

proper functionMinimize the symptoms of intestinal

malabsorption

Strategy Symptom Management

Nutrition Assessment

Should take place at diagnosis of HIV

Patient-Generated Subjective Global Assessment (PG-SGA)Dietary EvaluationPhysical AssessmentBiochemical AssessmentMedical History

Measuring Body Composition

AnthroprometricsTricep skinfoldMidarm Circumference

Bioelectrical impedance analysis (BIA)○ Convenient, inexpensive, and non-invasive

method for evaluating body composition – body cell mass

Dual energy x-ray absorptiometry (DEXA)○ Measures subcutaneous and visceral fat stores

Biochemical Assessment Selected biochemical measures for HIV

Immunologic○ CD4 count○ Viral Load

Hematologic○ Hemoglobin○ Hematocrit○ Mean Corpuscular Volume○ Ferritin

Transferrin Albumin Prealbumin

(Transthyretin)

Organ FunctionASTALTBUNCreatinine

EndocrineGlucoseInsulinGlycoslated

Hemoglobin A1CTestosterone

Cardiovascular Total Cholesterol HDL LDL Triglycerides C-Reactive Protein

Electrolytes Sodium Potassium

Energy & Protein Needs Energy – based on need to maintain weight

Harris-Benedict Formula X 1.3 (wt maintenance ) and 1.5 (wt gain)

In the presence of fever increase 13% of the BEE Protein – increased for infection

1.0 – 1.4 g/kg/day (maintenance) & 1.5 - 2 g/kg/day ( repletion)

In the presence of fever increase 10% of the total prot

Needs vary depending on disease status, presence of opportunistic infection or other underlying medical conditions

Micronutrient Needs Dietary Reference Intakes

Vitamin A – 700-900 μg/day○ Immune function

Vitamin E – 15 mg/day○ Immune function – antioxidant protection

Vitamin B12 – 2.4 mcg/day○ Cognitive function

Selenium – 55 μg/day○ Immune function – antioxidant protection

Zinc – 8-11mg/day○ Immune function, slowed disease progression

Fluids & Electrolytes

Fluids : 30 -35 ml/kg (8 -12 glass) Replacement of electrolytes (sodium,

potassium, and chloride) in the presence of diarrhea and vomiting.

Symptom ManagementNausea and Vomiting

○ Replace fluids and electrolytes○ Bland, odorless foods○ Beverages between meals○ Smaller, more frequent meals○ Reduce fatty foods with early satiety

Diarrhea○ Replace fluids and electrolytes – juice, sports drinks,

gelatin○ Bland foods low in fiber and residue○ Avoid fatty and gassy foods○ Avoid lactose if problematic

Anorexia○ Eat favorite foods often in relaxed settings○ Add flavors and an array of colors○ Keep snacks handy ○ Appetite stimulants

Oral lesions/chewing & swallowing problems○ Moist, soft, and finely diced foods○ Avoid spicy or acid-containing foods○ Room temperature or cooler foods○ Thickened liquids (swallowing)○ Topical medicines

Nutrient Supplementation Specific micronutrient supplementation has shown

various results, and general multivitamin supplementation is recommended, while food should be considered the main source of nutritional needs.Double-blind, placebo-controlled trail in Thailand – 21

nutrient multivitamin (N=481)○ Significantly reduced risk of mortality in men and women

Observational study amount HIV-infected men in U.S. taking daily multivitamin supplement (N=296)○ 30% reduction in risk of progression to the diagnosis of

AIDS○ Significantly reduced risk for low CD4+ counts

High energy, high-protein oral supplementProspective intervention trial (N=17) Boston, MATake one high-energy, high protein, oral, liquid,

nutrition supplement daily for 6 weeks along with dietary counseling

Upon entry, 16 of 17 averaged 14% below UBW10 gained weight, 2 maintained4 lost weight – possibly due to secondary

infectionMean weight gain = 1.1 kg

Glutamine (GLN) -Antioxidant SupplementationIncrease body cell mass in AIDS patients

with weight loss○ Randomized, double-blind controlled trial (N=21)○ Patients with >5% wt. Loss since disease diagnosis○ Treatment group: 40.0 g/d GLN, 800 mg/d ascorbic

acid, 500 IU/d α-tocopherol, 27,000 IU/d β-carotene, 280 µg/d, and 2400 mg/d N-acetyl cysteine for 3 mo.

○ Treatment group gained 2.2 kg (3.2%) body weight and gain 1.8 kg in body cell mass vs .3 kg body weight and .4 kg body cell mass in control group

Conclusion

HIV/AIDS is a complicated disease and requires critical assessment by a multidisciplinary team

Maintenance of body weight and composition is crucial in delaying HIV/AIDS progression

Malnutrition leading to AIDS Wasting is of primary concern in MNT

Symptom management is an effective way to address factors leading to AIDS wasting

Nutrient supplementation may be necessary to ensure weight and body composition maintenance

Questions?

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Thank you…

“Do What you Can

with what you Have

Where you Are !”

Assignment….

Nutrition & Bone health Nutrition for oral & dental health MNT for psychiatric disorder