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Care of Women with HIV Living in Limited-Resource Settings

Overview of HIV and Nutrition

Ellen G. Piwoz, ScDDirector, Center for Nutrition

Nutrition Advisor, SARA ProjectAcademy for Educational Development

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Objectives

Review effect of HIV and AIDS on nutrition Discuss impact of nutrition interventions on HIV

progression and mortality Describe nutritional considerations in mother-to-child

transmission of HIV

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Types of Malnutrition

Protein-energy malnutrition (PEM) Measured in terms of body size

Micronutrient malnutrition Often referred to as “hidden hunger” Not easy to see unless it is severe

Iron, vitamin A and iodine are the most commonly reported micronutrient deficiencies in both children and adults Deficiencies of other nutrients common in settings with infectious

diseases, food insecurity

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Consequences of Malnutrition in Women

Increases women’s morbidity and mortality Zinc, vitamin A deficiencies increase the risk of sexually

transmitted diseases Iron deficiency reduces resistance to disease, causes fatigue, and

reduces women’s productivity Low calcium intake increases risks of pre-eclampsia, high blood

pressure and hypertension during pregnancy Anemia increases risks of prolonged labor, and death due to

hemorrhage

Affects infant birth outcome and health Intrauterine growth and birth weight Nutrient stores for later development Growth and survival

Source: Huffman et al 2001.

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Effects on Immune System

Malnutrition HIV

CD4 T-lymphocyte number

CD8 T-lymphocyte number

Delayed cutaneous hypersensitivity

CD4/CD8 ratio

Serologic response after immunizations

Bacteria killing

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How Does HIV/AIDS Affect Nutrition?

Causes a decrease in the amount of food consumed Impairs nutrient absorption Changes metabolism

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Causes of Decreased Food Consumption

Mouth and throat sores Fatigue, depression, changes in mental state Loss of appetite Side effects from medication Household food insecurity

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Poor Nutrient Absorption

Nutrient absorption impaired during many infections Poor absorption of fats and carbohydrates occurs at all

stages of HIV infection Causes:

HIV infection of intestinal cells Frequent diarrhea

Poor absorption of fats affects use of fat-soluble vitamins, such as vitamins A and E

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Changes in Metabolism

Infection increases energy and protein requirements 10–15% increase in energy needs 50% or greater increase in protein requirements

Infection also increases demand for antioxidant vitamins and minerals Vitamins – E, C, beta-carotene Minerals – zinc, selenium, iron

When antioxidants are not sufficient, oxidative stress occurs. Increases HIV replication Leads to higher viral loads

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Increased HIV replication

Hastened disease progression

Increased morbidity

Nutritional deficiencies

Increased oxidative stress

Immune suppression

Insufficient dietary intakeMalabsorption, diarrheaAltered metabolism and

nutrient storage

Source: Semba and Tang 1999.

The Vicious Cycle of Malnutrition and HIV

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Can Improved Nutrition Slow

HIV Disease Progression?

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Observational Studies on Nutrition on HIV/AIDS

Early observational studies showed: Weight loss associated with HIV infection, disease progression,

mortality Some nutrient deficiencies (vitamins A, B12, E, selenium, zinc)

associated with HIV transmission, disease progression and mortality

Observational studies do not tell us whether these conditions caused more rapid progression or resulted from it

Clinical trials are required to show that improving nutrition can slow HIV disease progression and increase survival

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Clinical Trials on Nutrition and HIV/AIDS

Interventions to increase energy and protein intake in people living with HIV may reduce vulnerability to weight loss and muscle wasting.

High-energy, high-protein drink + counseling1

Weight gain, maintenance in HIV+ with no symptoms Omega-3 fatty acids (common in fish oils, seeds)2

Weight gain in some AIDS patients Glutamine+antioxidants+counseling3

Weight gain, improved body cell mass in HIV+ who had begun to lose weight

Source: 1 Stack et al 1996 2 Hellerstein et al 1996 3 Shabert et al 1999.

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Clinical Trials on Nutrition and HIV/AIDS continued

Improvements in micronutrient intake and status may help strengthen the immune system, reduce consequences of oxidative stress and lengthen survival.

Vitamin A1,2 Improved immune status, reduced diarrhea and mortality in HIV+ children.

Vitamin B123

Improved CD4 cell counts in HIV+ men Vitamin E, C4,5

Reduced oxidative stress and HIV viral load

Source: 1 Coutsoudis et al 1995 2 Fawzi et al 1999 3 Baum et al 1995 4 Allard et al 1998 5

Kelly et al 1999.

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Clinical Trials on Nutrition and HIV/AIDS continued

Selenium and beta-carotene1

Increased antioxidant enzyme functions Zinc2,3

Reduced incidence of opportunistic infections, stabilized weight, improved CD4 counts in adults with AIDS

Reversing anemia4,5

Slowed HIV progression and improved survival

Source: 1 Delmas-Beauvieux et al 1996 2 Mocchegiani et al 2000 3 Tang et al 19964 Sullivan et al 1998 5 Moore et al 1998.

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How Does Nutrition Affect

Mother-to-Child Transmission of HIV?

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Mother-to-Child Transmission (MTCT) of HIV

HIV is transmitted from mother to infant during pregnancy, at the time of childbirth, and through breastfeeding. Not all infants become infected Difficult to distinguish between transmission in late pregnancy,

labor and delivery, or early breastfeeding

Without interventions to prevent MTCT, about 25-40% of infants become infected. 5-10% are infected during pregnancy 10-20% are infected during childbirth 10-20% are infected over 2 years of breastfeeding ~ 600,000 infants infected per year worldwide

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Nutrition and MTCT – Possible Mechanisms

Maternal malnutrition can lead to: Impaired immune system

More severe and frequent secondary infections Decreased CD4 cell counts

Increased viral load in blood, genital secretions, breast milk Low serum retinol1,2,3

Low serum selenium4

Increased risk of low birth weight, prematurity Low fetal nutrient stores

Weakened infant immune system Impaired integrity of mucosal barrier

Genital mucosa, placenta Infant gastrointestinal tract, impaired mucosal immunity

Source: 1 Semba et al 1994 2 Nduati et al 1995 3 John et al 1997 4 Baeten et al 2001.

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Clinical Trials on Nutrition and MTCT

Clinical trials providing Vitamin A or multivitamin supplements to prevent MTCT carried out in several African countries Tanzania, South Africa, Malawi, Zimbabwe Supplements provided during pregnancy, after childbirth

Generally, these supplements had no overall impact on MTCT during pregnancy or delivery In South Africa, MTCT by 6 weeks reduced by 47% in preterm

infants in vitamin A group1

Impact of vitamin A and multivitamin supplementation on MTCT during breastfeeding still under study Tanzania, Zimbabwe

Source: 1 Coutsoudis et al 1999.

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Clinical Trials on Nutrition and MTCT continued

Although MTCT was not reduced, other benefits for mother and newborn were observed: In South Africa, daily vitamin A in 3rd trimester reduced risk of

preterm birth by 34%1

In Tanzania, daily multivitamin supplements (B1, B2, B6, Niacin, B12, C, E, folic acid) improved maternal immune status and reduced risks of:

Fetal death by 39% Low birth weight by 44% (if HIV- at birth) Small size for gestational age by 43% Severe preterm birth (< 34 wks) by 39% 2

Source: 1 Coutsoudis et al 1999 2 Fawzi et al 1998, 2000.

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Other Considerations During Pregnancy

Physiological changes that occur during pregnancy require extra nutrients for: Adequate gestational weight gain Growth of the developing fetus

Poor absorption and excess nutrient losses due to HIV further increase nutritional requirements Recommended levels still unknown

HIV-infected women may be more vulnerable to anemia, a common problem during pregnancy In West Africa, 78-83% of HIV+ pregnant women are anemic1

Source: 1 Ramon et al 1999.

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Impact of Breastfeeding on Maternal HIV Disease Progression

The impact of breastfeeding on maternal HIV disease is not well understood The increased nutritional demands of lactation may affect weight

loss, a risk factor for disease progression In Kenya, breastfeeding mothers were more likely to die than

mothers who did not breastfeed (11% vs. 4%)1

In South Africa, breastfeeding mothers were not at increased risk of morbidity or death (0.5% vs. 1.9%)2

WHO recommends further research on the impact of breastfeeding on maternal health before any change to breastfeeding policy

Source: 1 Nduati et al 2001 2 Coutsoudis et al 2001.

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Nutrition Recommendations for HIV+ Women

Improve weight, nutrient stores Improve diet and eating habits Take multivitamin supplements if diet is not adequate

Promote hygiene and food safety To avoid pathogenic contamination, diarrhea

Provide a holistic package of care including: Supportive counseling Medical care

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Nutrition Recommendations for Pregnant HIV+ Women

Provide optimal antenatal, postpartum care Ensure adequate weight gain during pregnancy Give iron-folate supplements Provide other nutritional supplements, where available Promptly treat all conditions that affect food intake or risk of

MTCT Provide ARV drugs, if available

Fully inform women about infant feeding options, risks Support women in feeding decisions Provide nutrition support for breastfeeding mothers

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Summary

HIV affects nutrition in many ways The impact begins early in the course of HIV infection,

even before other symptoms are observed Nutritional status also affects HIV disease progression

and mortality Improving nutritional status may improve some HIV-

related outcomes

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Summary continued

The impact of different nutrition interventions depends on the stage of disease Counseling and other interventions to prevent weight loss are likely to

have their greatest impact early in the course of HIV infection Nutritional supplements, particularly antioxidant vitamins and minerals,

may also improve HIV-related outcomes, particularly in nutritionally vulnerable populations

HIV-positive women are at greater risk of malnutrition than uninfected women during pregnancy and breastfeeding

Meeting the nutrient and energy requirements of HIV-infected mothers will improve both maternal and infant health