HIV/AIDSPresented by

Libby SellsLisa Sharp-Gomez

Overview Disease

Etiology Diagnosis Treatment

Patient Assessment Diagnosis Intervention Treatment Medical Nutrition Therapy Monitoring and Evaluation Prognosis Resources

Disease Description and Etiology

Definition HIV is a retrovirus that targets the CD4 cells of the

immune system (the T-Helper cells) and turns them into viral factories for HIV reproduction

Transmission The HIV virus is transmitted from person to person

via infected body fluids. This includes sexual contact, infected needles, blood transfusions and mother to child.

AIDS is the advanced manifestation of HIV that has the potential to make a person vulnerable to opportunistic infections

Diagnosis of HIV and AIDS Diagnostic tests

ELISA - Enzyme Linked Immunoabsorbant Assay Western Blot IFA- Indirect Immunoflorescent Antibody RIPA - Radio Immunoprecipitation PCR - Polymerase Chain Reaction

Alternative diagnostic tools Urine and oral fluid tests Finger prick

CDC Clinical and Immune Cell Categoies of HIV Infection

Categories Sample CriteriaPrimary HIV Infection

Acute retroviral syndrome, but no complicating opportunistic infection or immune dysfunction

Clinical Stage 1 Primarily asymptomatic as above, possible persistent generalized lympadenopathy

Clinical Stage 2 Weight losses that are <10% of body weight, herpes zoster, minor mucocutaneous manifestations, recurrent bacterial upper respiratory tract infections, fungal infections of fingers, papular pruritic eruptions, or seborrhoeic dermatitis

Clinical Stage 3 Weight loss of >10% of body weight, persistent constitutional symptoms (fever, diarrhea), oral candidiasis or hairy leukoplakia, acute necrotizing ulcerative gingivitis or necrotizing ulcerative periodontitis, pulmonary tuberculosis, severe bacterial infections, unexplained anemia, neutropenia and or thrombocytopenia for more than a month (confirmatory testing is required for anemias)

Clinical Stage 4 HIV wasting syndrome (>10% weight loss with chronic diarrhea, weakness, fever), opportunistic events as described in Clinical Category 3 as well as chronic herpes simplex virus, recurrent severe or radiological bacterial pneumonia, pneumoncystitis pneumonia, Kaposi’s sarcoma, CMV, cryptosporidiosis, isopsoriasis, any disseminated mycosis (eg. Coccidiomycosis, histoplasmosis, penicilliosis) recurrent non-typhoidal salmonella septicaemia and or lymphoma (cerebral or B cell non Hodgkin)

HIV and AIDS Treatment There is no cure. Treatment is by symptom

management only. Treatment includes anti-viral medications,

prevention and treatment of opportunistic infections (OI) and restoration of nutritional status

Treatment is multi dimensional involving physicians, dietitians and psychologists

A person’s geno- and phenotype can help determine the appropriate therapy.

Anti Retro Viral Medications The goal is to lower the viral load (copies of the virus per

ml of blood) Medications interrupt the viral life cycle, thus decreasing

the spread from cell to cell within the body. HAART – Highly Active Anti Retroviral Therapy

Includes 3 or more ARV medications

Side Effects: Nausea, diarrhea, appetite loss, lipid alterations and glucose

intolerance. Lipodystrophy

Opportunistic Infections Examples: Pneumonia, Encephalitis, tuberculosis,

Influenza, HPV, Hepatitis A and B and Malaria Early detection is important Vaccines are useful in preventing some infections

like HPV and Hepatitis

AIDS Wasting Syndrome Treatment

Defined as weight loss greater than 10% of body weight combined with fever or diarrhea for more than 1 month. Or 7.5% weight loss in 6 months

Megestrol Acetate and Dronabinol are used to increase appetite and reduce nausea.

Strength building exercise can be used to retain muscle mass

May also be managed with Androgens and Growth Hormones This hormone therapy is also used to manage

lipodystrophy

Alternative Supplements and Oral Therapies

GINSENG American ginseng is used for other infections including HIV/AIDS, infections of the intestine (dysentery), and particular infections (Pseudomonas infections) that are common in people with cystic fibrosis.Some people use American ginseng to improve digestion and for loss of appetite, as well as for vomiting, inflammation of the colon (colitis), and inflammation of the lining of the stomach (gastritis).

MILK THISTLE (SILYMARIN)

Silymarin exerts membrane-stabilizing and antioxidant activity, it promotes hepatocyte regeneration; furthermore it reduces the inflammatory reaction, and inhibits the fibrogenesis in the live

ECHINACEA Anti-Cancer, immunostimulatory, may inhibit metabolism of drugs using the cytochrome P 450 enzyme pathway.

ST. JOHNS WORT

Anti-depressant, anti anxiety, anti HIV, contraindicated with the use of medications processed by the CYP3A4 and P glycoprotein Pathways, including protease inhibitors and NNRTI’s, reduced effectiveness of oral contraceptives, antagonistic to antihypertensive medications

Patient Assessment and Etiology

Etiology – Unknown Terry Long , 32 years old. African American male, HIV positive for

4 years, diagnosed with Stage 3 AIDS and oral thrush. Family history of CAD and HTN, stopped smoking 5 years ago, consumes 2-3 drinks 3-4 x/week. Taking multivitamin, vitamin E, vitamin C, ginseng, milk thistle,

Echinacea, St. John’s wort, prescribed HAART regime with Atripla and Fluconazole IV

Anthropometrics Weight – current 151, usual 165, % UBW 91.5 BMI 19.9 kg/m2 TSF 7mm < 50 percentile BP 120/84 12.5% body fat

Patient Assessment and Etiology

Patient Assessment and Etiology Clinical

White patchy exudate in throat Dry, warm, flaky skin Rhonchi in left lung Hyperactive bowel sounds

Diet Current - Liquid and soft foods due to mouth pain

Usual diet - 2000 kcal intake 52% from carbohydrates 37% from fats 15% from protein

540 non nutritive calories from alcohol

Current Diet – 860 calories 70% from carbohydrates 25% from fat 5% from protein

Patient Diagnosis 1) Unintentional weight loss (NC-3.2) related to

HIV/Aids, difficulty swallowing and inadequate caloric intake as evidenced by BMI of 19.2, 91% UBW and recent weight loss.

2) Difficulty swallowing (NC-1.1) related to oral thrush as evidenced by patient’s complaints and 24 hour diet recall.

Stage 3 AIDS with oral thrush.

Patient Intervention and Treatment

Multidisciplinary approach to treatment Priorities: concern for diabetes, insulin resistance,

hepatitis, renal and pancreatic malfunctions, cardiovascular disease and osteoporosis

Goals Prevention of food, drug and supplement

interactions Restoration and maintenance of nutritional status Management of signs and symptoms

Appetite loss Diarrhea Heartburn/reflux Nausea/vomiting Oral lesions

Medications/SupplementsTaken By Patient

Supplement

Proposed Use in HIV/AIDS Potential Risks

Vitamin C Improve antioxidant capacity, increases iron absorption from non-heme sources

Increases urinary losses of oxalate and calcium

Vitamin E May protect against toxicity and sice effects from AZT (antiretroviral medications)

Can interfere with blood clotting, cause nausea, diarrhea, muscle weakness fatigue

Ginseng Anti-stress and anti-fatigue effects, may contain a protein with anti-HIV activity

Morning diarrhea, insomnia, nervousness, depression, confusion, skin rashes, high blood pressure

Milk Thistle May prevent liver damage caused by ARV medications Upset stomach, diarrhea, bloating, gas

Echinacea Anticancer; immuno-stimulatory; promotes CD4 cell activation

May inhibit metabolism of drugs sing the cytochrome P450 enzyme pathway

Multivitamin Slows disease progression, increases CD$ count, lowers viral load values

None

Medication Proposed Use Interactions

Efavirenz Controls HIV infection by decreasing the amount of HIV in the blood and may decrease chance of developing AIDS and HIV related illnesses like serious infections or cancer

May interact with products that contain Kava or St. John’s Wort. Avoid alcohol and take on an empty stomach

Tenofovir DF Interferes with HIV replication in the body High fat meals increase bioavailability. Avoid alcohol as it can worsens side effects

Emtricitabine Inhibits the enzyme that copies HIV RNA into new viral DNA. Can help lower the amount of HIV in the body and increase the number of CD4+ cells

Avoid alcohol as it can worsen side effects

Physical Activity Recommendations

Exercise known to improve muscle volume and functionRegulates lipid and energy metabolismFor patients with HIV/AIDS may lessen the loss of muscle mass in wasting conditions.Recommendations should complement diet prescriptionExercise should include a combination of aerobic and resistance training.

Medical Nutrition Therapy As infected cells in the gut increase, there is an

increased risk of malabsorption and malnutrition increase

ARV’s can increase blood lipid levels and inflammation, diabetes and hypertension can put patients at an increased risk for cardiovascular diseases.

HIV can affect all body systems causing a variety of nutritional complications.

Nutrient Requirements Fluids: 1 ml/kcal = 3 L per day Calories: 2900 – 3300 actual calculated 2400

calories, but increase 20-50% due to OI. Protein: 59 grams based on current body weight, or

145 grams based on 20% of 2900 calories. Fat: Less than 97 grams of total fat and less than 26

grams saturated fat. Vitamin and mineral recommendations based on

individual needs and deficiencies

Goals and Intervention Goal 1: Increase weight to at least UBW of 160-165

pounds, with ultimate goal of 184 pounds (ideal body weight).

Intervention 1:Increase caloric intake to at least 2900 calories, which will allow a weight gain of at least 1 pound/week. Do this by consuming smaller, more frequent meals, add in protein shakes and hidden sources of calories.

Goal 2: Alleviate signs and symptoms associated with oral thrush

Intervention 2: Avoid alcohol, high sugar and yeast foods, and foods that are hot, spicy, tough, and difficult to chew and swallow.

Sample Diet and Modifications

Breakfast Lunch Dinner-Scrambled eggs with hot salsa-Crisp bacon-Apple-Orange juice 

-Spaghetti with sauce-White roll-Chocolate ice cream 

-Steak and potatoes -Raw carrot sticks-Beer

When is Enteral Nutrition Necessary? Enteral Nutrition may be considered when BMI drops below

18.5 kg/m2

Enteral nutrition may be considered when a weight loss of greater than 5% occurs in a 3 month period.

Enteral nutrition may be considered when BCM (Body Cell Mass) decreases by more than 5% in 3 months.

Can be considered if Oral Thrush worsens to the point that patient is unable to consume adequate nutrition from food sources

Can be considered in malnourished AIDS patients with chronic, uncontrollable diarrhea.

Education and Counseling Focus on diet modification and food safety Provide patient with food/drug and supplement

interactions information and symptom management information

Food safety suggestions What would you advise?

Monitor and Evaluation BMI, body composition changes, skin fold

measurements Pertinent lab values: CD4 count, viral load,

albumin, glucose, cholesterol, etc. Signs and symptoms like diarrhea and fatigue Development of additional opportunistic

infections Oral thrush, pneumonia, AWS

Evaluate patient’s adherence to diet modifications and exercise

Prognosis Weight loss and AWS is not inevitable. Opportunistic infections and other complications

of AIDS will always affect nutritional status, so nutrition therapy and continuing education will be important for patient’s entire life

Life expectancy depends on how early patient began ARV, and how well they are able to prevent nutritional complications and OI. Life expectancy is near normal today if disease is

properly managed

Resources Resources

Alcohol and HIV/AIDS. National Institute of Alcohol Abuse and Alcoholism. (2002). http:pubs.niaaa.nih.gov/publications/aa57.htm Body Fat Percentages. Vanderbuilt University (2012). http://

healthandwellness.vanderbilt.edu/news/2011/09/body-fat-percentage/ HIV. Centers for Disease Control and Prevention. (2013). http://www.cdc.gov/hiv/.

HIV Infection. U.S. National Library of Medicine. (2012). http://www.nlm.nih.gov/ medlineplus/ency/article/000682.htm Nelms, Sucher, Lacey, Roth; (2011)Nutrition Therapy & Pathophysiology, (2nd

ed.) Belmont, Ca, Brooks/Cole Cengage Learning Mahan, Escott-Stump, Raymond, (2012) Food and the Nutrition Care Process, St.

Louis, Mo, Elsevier Saunders