Wednesday, October 22, 2008


By James Achanyi-Fontem

HIV infection not only compromises the nutritional status of infected individuals, but poor nutritional status can affect the progression of the infection. Research to identify nutritional interventions has been undertaken in Africa by the Commonwealth Regional Health Community Secretariat in Africa seeking to:
•review what is known about the clinical and social dimensions of HIV and nutrition
•synthesise current understanding of the role of macro and micro nutrients in HIV
•describe the impact of HIV on nutritional status and the impact of nutritional status on HIV progression and transmission particularly mother-to-child transmission (MCTC)
•highlight important research from Africa
•identify gaps in research and make recommendations.

Epidemiology and social impact
Although the number of infected people is increasing in Cameroon, HIV/AIDS affects a disproportionate number of young women and large number of children. Declining life expectancy and changing population structure are harming economic and social development, including food security, illness and death from AIDS cab profoundly affect a family’s ability to provide adequate food and nutrition for its members, particularly for young children who are already vulnerable.
An estimated 12 million children in Africa have lost one parent or both before the age of 15. This highly vulnerable group is expected to grow dramatically.

Paediatric HIV/AIDS
Infants can acquire HIV from their mothers during pregnancy, at the time of delivery ,or during breastfeeding. If no interventions are in place to prevent mother-to-child transmission, about 5 – 10% of infants will be infected during pregnancy, about 10 – 20 % will become infected during delivery; and another 10 – 20% will become infected fi breastfed to one year or longer.
In these cases, children are more likely to suffer from failure to thrive and low weight-for-age than uninfected children. Disease progression may be more rapid than among children in industrialised countries because of endemic malnutrition, frequent exposure to infectious diseases, and limited access to health care and treatments.
According to the WHO recent clinical approach to diagnosing HIV in children living where testing is not available, the following guidelines suggest that, where three out of seven conditions are present, HIV infection should be suspected. These are the seven conditions:
*two or more chest infections requiring antibiotics (pneumonia) in the past two months
•one or more episodes of persistent diarrhoea or two or more episodes of acute diarrhoea in the past two months
•a patient with tuberculosis
•oral candidacies (thrush)
•enlarged lymph nodes in tow or more sites
•growth faltering (weight curve flat or falling for two consecutive months)
•weight-for-age below the 3rd percentile, using international growth reference standards.

Malnutrition in its many forms is endemic and measurements of body size indicate protein-energy malnutrition, but micro nutrient malnutrition in its milder forms is not easily recognised. The most commonly reported micro nutrient deficiencies are iron, vitamin A, and iodine.
Deficiencies in other vitamins and minerals are not commonly reported , but occur frequently where diets are lacking in variety and contain few animal products. Malnutrition in children is increasing due to HIV/AIDS and other factors that affect food security , access to health care, and family caring practices. Vitamin A deficiency is widespread, and about 60% of African children under five years , and half of all pregnant women , suffer from anaemia.

The clinical context
Nutritional status affects the progression of HIV disease . Infectious diseases, no matter how mild, influence nutritional status. Conversely nutritional deficiency, if sufficiently severe, will impair resistance to infection.
Infants and young children are frequently malnourished, so the differentiation of HIV malnutrition from other causes is difficult. HIV not only destroys the CD4 cells of the immune system, but also affects the cells of the intestine, brain and other organs.
Infections lead to reduced dietary intake and nutrient absorption, whilst increasing utilisation and excretion of proteins and micro nutrients. The immune system responds to infection by releasing pro-oxidant cytokines, which demand increase demand for and utilisation of anti-oxidant vitamins and minerals.
Oxidative stress occurs when there are not enough antioxidants to form enzymes needed to respond to the pro-oxidant immune response. Oxidative stress may hasten HIV replication and increase production of hormones involved in the metabolism of carbohydrates, proteins and fats, contributing to further weight loss.

The social context
Quality of life is seriously affected by HIV infection. Weight loss leads to fatigue and decreasing physical activity. Entire families are affected when infected adults cannot work steadily and provide for their dependants, but face increased expense when infected members require medication and continued care.
A common result is food security, which is especially severe in female-headed households and in areas where farming is a primary occupation. Parental death is a frequent precipitating cause of childhood malnutrition.

Weight loss and wasting in HIV/AIDS
The syndrome once known as ‘slim disease’ typically found in AIDS patients is a severe nutritional manifestation of the disease. In earlier stages of HIV infection, weight loss typically follows one of two patterns: slow and progressive weight loss from anorexia and gastrointestinal disturbances, and rapid episodic weight loss from acute infection.

Sometimes overlapping processes cause weight loss and wasting.

1. Reduction in food intake due to physical or psychological factors affecting food availability and nutritional quality, and the side-effects of drugs.
2. Nutrient malabsorption due to frequent diarrhoea and possible damage to intestinal cells by the virus. Fat malabsorption also affects the absorption and utilisation of fat-soluble vitamins (A,E), further compromising nutritional and immune status).
3. Metabolic alterations is also a serious problem. Infection results in increased energy and protein requirements. Furthermore , severe reduction of food intake can cause changes in metabolism, as the body uses up carbohydrate reserves and begins to break down protein to produce glucose, causing muscle – wasting cachexia. This process occurs when skeletal muscle is broken down for proteins required to bind and clear infectious agents.
Malnutrition due to the first two processes may be reduced by treating the immediate source of the problem (other infections) and providing well-tolerated foods to the infected individual, whilst increasing food intake during convalescence.
Weight loss and wasting due to metabolic changes cannot be reversed by feeding alone. Industrialised countries have used expensive appetite stimulants and hormones to treat wasting in AIDS patients. However, a less expensive supplement on weight again appeals to depend upon the stage of the disease. Nutrition supplementation combined with glutamate and antioxidants appears to be effective over a 3-month period .
Other nutritional supplements tested, such as fish oil supplements and high energy-protein drinks, have resulted in improved weight again among some HIV-infected adults. The impact of these supplements on weight again appears to depend upon the stage of the disease. Nutrition supplementation combined with counselling about appropriate diet has had the greatest impact before the onset of chronic secondary infections. Unfortunately, relatively few people in Cameroon learn of their status early in the disease, in time to take preventive actions.

Vitamins and minerals in HIV/AIDS
The table below summarises the role of vitamins and minerals in supporting body functions and the immune system. HIV – infected individuals have decreased absorption, excessive urinary loss, and low blood concentrations of several nutrients.
It is not known if these deficiencies are independent markers of disease progression or whether they are causally related to the worsening symptoms of HIV/AIDS. But low intakes and pre-existing malnutrition are likely to worsen the impact of HIV on immune function.
Metabolic alterations that accompany acute infections
Increased urinary nitrogen loss
Increased protein turnover
Decreased skeletal muscle protein synthesis
Increased skeletal muscle breakdown
Increased hepatic protein synthesis
Lipid (Fat)
Increased hepatic de novo fatty acid synthesis
Increased hepatic triglyceride esterification
Increased very low-density lipoprotein production
Decreased peripheral lipoprotein lipase activity
Increased adiposity triglyceride lipase
Insulin resistance
Increased peripheral glucose utilisation
Increased gluconeogenesis
These are causally related to the worsening symptoms of HIV/AIDS; But low intakes and pre-existing malnutrition are likely to worsen the impact of HIV on immune function.

Haem iron sources (high absorption) include red meat, liver, fish, poultry , shellfish. Non haem iron sources (low absorption) include eggs, legumes, peanuts, some cereals, and dried fruits.
Vitamin C, haem iron foods and some fermented foods increase non-haem iron absorption. Tea, coffee and some grains and green leafy vegetables (with phytate) decrease non-haem iron absorption.
Required for building strong bones and teeth. Important for normal heart and muscle functions, blood clotting and pressure, and immune defences. Milk, yoghurt, cheese, green leafy vegetables, broccoli, dried fish with bones that are eaten, legumes, peas.
Important for function of many enzymes. Acts as an anti-oxidant. Involved with making genetic material and proteins, immune reactions, transport of vitamin A, taste perception, wound healing, and sperm production. Meat, fish, poultry, shellfish, whole grain cereals, legumes, peanuts, milk, cheese, yoghurt, vegetables.
Acts as an antioxidant together with vitamin E. Prevents the impairing of heart muscles. Meat, eggs, sea food, whole grains, plants grown in selenium rich soil.
Important for building strong bones and teeth, protein synthesis, muscle contraction, transmission of nerve impulses. Nuts, legumes, whole grain cereals, dark green vegetables, sea food
Iodine Ensures the development and the proper functioning of the brain and of the nervous system. Important for growth, development, metabolism Sea food, iodised salt, plant grown in iodine-rich soil.
Micro nutrient deficiencies:
•vary across populations and according to disease stage
•are associated with accelerated progression of the disease
•are predictive of HIV-associated mortality.
Micro nutrient supplementation has thus the potential to be an affordable public health measure.
Selenium deficiency is unusual in most populations of Cameroon. Deficiency impairs the immune system and has been associated with faster HIV progression. Selenium is believed to play an important role in reducing oxidative stress and animal studies suggested that lack of it increases viral pathogenicity.

Micronutrients and Mother-to-Child- transmission (MCTC) of HIV

High viral load due to recent or advanced infection increases the likelihood that HIV will pass on to the baby during pregnancy, delivery, or breastfeeding. If malnutrition –facilitated immune suppression contributes to high viral load, then the risk of MCTC is greater. Some micronutrient deficiencies during pregnancy (vitamin A and zinc) result in reduced foetal nutrient stores, which may affect their immune status and subsequently increase their vulnerability to HIV.
In addition, malnutrition during pregnancy may further erode the woman’s immune status and possibly accelerate disease progression. According to studies carried out, breastfeeding mothers with HIV lost more weight and died earlier than those also HIV infected who did not breastfeed.

Interpreting the results
What is known to favour the continuous increase in the HIV figures in Africa than in the industrialised countries could be related to the following views:
•The general level of nutrition is higher in industrialised countries than in Africa. Nutritional interventions may therefore have a greater impact in Africa.
•Most studies of adults in industrialised countries have been among homosexual men and /or drug users. Their diet and health status are likely to be quite different from HIV – infected adults in Africa.
•Most Americans and Europeans are taking anti-retroviral drugs and treatment for secondary infections, including nutritionally fortified foods and supplements. These are not generally available or consumed by Africans. Nutritional interventions have had a positive impact in populations also receiving antiretroviral drugs.

HIV+ and Nutrition Support
Nutrition programmes serving people with HIV/AIDS have significantly increased their quality of life. Programmes addressing the needs of people living with HIV and AIDS can have varied objectives. These objectives will depend on the needs of the population and the stage of HIV disease in individual participants.
For people with HIV but no opportunistic or secondary infections, programmes should focus on building nutrition stores to prevent nutrition deterioration. People with AIDS, at the other end of the spectrum, will require palliative nutrition care.
Specific objectives for nutritional care and support programmes may include:
•improving nutrition, diet and eating habits
•building or replenishing body stores of Micronutrients
•preventing weight loss
•preserving muscle mass
•preventing food borne illness
•preparing for and managing AIDS related symptoms that affect food consumption
•ensuring that nutritious food is available to AIDS-affected families
Nutritional support should be provided within the context of holistic care and people with HIV/AIDS should be allowed to participate in providing programme services .
Components of a holistic care programme include counselling for emotional and psychological stress, physical exercise , health care and treatment of opportunistic infections. Nutritional programmes may include one or more of the following :
•education regarding diet
•safe water , personal hygiene , and food safety
•support for healthy members of family affected by HIV/AIDS
•nutrition supplements , group meals, or food baskets
•home-delivered ready-to-eat foods for AIDS patients

Recommendations for nutrition care
Recommendations vary according to the nutritional status, stage of infection, and level of disease. In the asymptomatic stage, advice will focus on maintaining health and building nutrition stores in the body.
In later stages, advice may shift to address the problems of anorexia, infections causing protein catabolism, and to mitigate the adverse nutritional effects of chronic diarrhoea and other secondary infections.
Nutritional support is more likely to be effective during the early stages of the disease, but this requires early diagnosis and early detection of the disease is rare in Cameroon.
For HIV-positive asymptomatic individuals, a healthy diet that is adequate i terms of energy, protein, fat, and other essential nutrients should be promoted as a key component for positive living, and to prolong the period between HIV infection and the onset of secondary infections attributed to AIDS. Local available foods should be recommended and these should be familiar to all health care providers, and made accessible , along with sources of social support , to families affected by HIV/AIDS.
Nutritional counselling should include information on appropriate diets, taking into account the individual’s particular preferences and needs in terms of age, sex, and physiological state- for example, pregnancy, lactation, engaged in strenuous physical labour and so on.
Even those who are asymptomatic have increased metabolism due to the HIV infection. The potential for increasing nutritional reserves and improving dietary intake are greater when an individual is still relatively healthy. Therefore , programmes should emphasise building nutritional reserves at an early stage.
People with HIV/AIDS should be encouraged to maintain physical activity. Weight –bearing exercise may help build lean body mass. Exercise also stimulates appetite. Counselling should also include discussion on personal hygiene, safety in food preparation and cooking, and emphasise the importance of seeking immediate attention for digestive or other health related problems. Preventing food and water borne infections is especially important in people with compromised immune systems.
HIV-positive individuals experiencing weight loss
Most early weight loss is the result of depressed appetite during secondary infections, particularly diarrhoea. Nutrition advice for managing common conditions and maintaining intake by having more frequent meals, and well liked foods, suggests that intake should be increased during periods of recovery from infection.
All people with HIV/AIDS at whatever stage should be advised against unhealthy lifestyles that include alcohol consumption, tobacco and drug use, and unsafe sexual practices, which increase the risk of infections. They should be advised to have all infections treated immediately and completely, to maintain personal hygiene, and to prevent food contamination at all times.

Recommendations for nutritional support for people with HIV

The advice is similar except that the emphasis shifts from preventing to mitigating the nutritional consequences of the disease and preserving functional independence wherever possible. Preservation of lean body mass is important.
Protein-energy consumption should be maintained and medical recommendation should be followed for specific symptoms. Foods low in insoluble fibre and fat should be avoided to minimise gastro-intestinal discomfort and, during periods of nausea and vomiting, people should be encouraged to eat small snacks.
Fluid intake should be maintained at all times , especially during periods of diarrhoea. Specific eating times should be set and made pleasant and supportive. It should be noted that several medications against opportunistic infections have nutritional consequences or side effects such as nausea and vomiting.
In situation of food insecurity, programmes providing food supplements should insure that rations are of sufficient size to meet the needs of the HIV/AIDS patient and his /her dependants. All family members are extremely vulnerable in this situation.

Nutrition Care for children with HIV
Children with mothers who are HIV-positive are especially vulnerable, as a result of their own infection with HIV or because of the deteriorating health of one or both parents. In this case, recommendations should follow those for all young children but take into account the increased nutritional requirements that accompany the infection.
Children less than 2 years need to be fed patiently and persistently with supervision and love, especially as they are likely to be frequently ill. Solid foods can be introduced gradually in small portions at least three times a day, and by the time they are one year old most children can eat adult diet as long as food is cut or mashed and not too spicy.
Variety and foods containing essential vitamins are a priority – locally available fruits and vegetables, and animal products and fortified food if available. Nutritious snacks between meals can be provided to increase consumption.
The following guidelines are suggested for nutritional management of HIV infected children :
•regular monitoring of weight, growth, and development
•review of child’s diet at every health visit
•immunisation and prophylactic vitamin A supplements
•prompt treatment of any secondary infection and maintenance of food and fluid intake
•for those who are severely malnourished , local guidelines should be followed ; entered or parenteral nutrition should be considered if available.

Symptom Suggested strategy
Fever and loss of appetite
Drink high energy, high protein liquids and fruit juice
Eat small portions of soft, preferred foods with a pleasing aroma and texture throughout the day
Eat nutritious snacks whenever possible

Sore mouth and throat

Avoid citrus fruits, tomato, and spicy foods
Avoid very sweet foods
Drink high energy, high protein liquids with a straw
Eat foods at room temperature or cooler
Eat thick, smooth foods such as pudding, porridge, mashed potatoes, mashed carrots or other non acidic vegetables and fruits
Nausea and vomiting
Eat small snacks throughout the day and avoid large mealss
Eat crackers, toast, and other plain, dry foods
Avoid foods that have a strong aroma
Drink diluted fruit juices, other liquids, and soup
Eat simple boiled foods, such as porridge, potatoes, beans
Loose bowels
Eat bananas, mashed fruits, soft rice, porridge
Eat smaller meals more often
Eliminate dairy products to see if they are the cause
Decrease high – fat foods
Don’t eat foods with insoluble fibre (“roughage”)
Drink liquids often
Fat malabsorption
Eliminate oils, butter, margarine, and foods that contain or were prepared with them
Eat only lean meats
Eat fruit and vegetables and other low-fat foods
Severe diarrhoea
Drink liquids frequently
Drink oral rehydration solution
Drink diluted juices
Eat bananas, mashed fruits, soft rice, porridge
Fatigue, lethargy
Have someone pre-cook foods to avoid energy and time spent in preparation( care with re-heating)
Eat fresh fruits that don’t require preparation
Eat snack foods often throughout the day
Drink high energy, high protein liquids
Set aside time each day for eating

HIV was first detected in breast milk in the mid-1980s, creating problems as to how to advise HIV-infected mothers on the feeding of their infants. The risk of transmitting HIV through breastfeeding must be balanced against the risks that can result from not breastfeeding.
Breastfeeding is near universal in Cameroon, making it hard to conduct studies on the risks of artificial feeding. The lack of data makes it difficult to balance these risks. As at now, HIV prevalence is high and rising in pregnant women in Cameroon, so it is important that guidance should be developed to help reduce the risk of mother-to-child transmission (MCTC). It must be borne in mind that breastfeeding in Cameroon is recommended usually from birth and may continue in most cases to over 24 months, but also that complementary foods are often introduced within the first 3 months of life.
In the resource poor settings, the many benefits of breastfeeding become especially important and the risks associated with the alternatives to breastfeeding also become greater. In developing countries like Cameroon, the high cost and irregular supply of breast milk substitutes, and the lack of safe water to make up such foods, results in higher levels of morbidity and mortality for infants who are not breastfed.
Studies carried in Cameroon by Cameroon Link have found that babies who are not breastfed in the first month of life are six times more likely to die than breastfed babies. The protective effect of breastfeeding declines with age but remains significant for the first 8 months of infancy, and it is greatest among mothers with limited education.
In some district hospitals in Cameroon, for an HIV-infected mother, the decision whether to break with tradition and not breastfeed, or to run the risk of transmitting the virus through breastfeeding, imposes a heavy burden. A woman who does not breastfeed may be stigmatised and others will suspect she has HIV, and there could be many adverse social consequences.
A woman may try to hide her HIV status by breastfeeding but also use artificial feeding in an attempt to reduce the risks to the baby. This , however, exposes her baby to both sets of risks. For now , options for replacement of infant feeds to HIV-positive mothers and children for the first six months are discussed by the UN agencies like UNICEF,WHO, and WHA.
On the other hand, there is information on home-prepared foods for children over this age. These guide are generic and should be locally adapted. Through counselling, they should also be tailored to individual circumstances . Local guidelines are being developed in Cameroon, but little is known about their implementation or effectiveness. What is known is that it is difficult to achieve safe replacement feeding in Cameroon for now.

HIV transmission through breastfeeding
The mechanisms of HIV transmission through breastfeeding are not clear but the virus probably infects the infant through breaches in the integrity of the intestinal mucosa. An improved understanding of how HIV transmission through breastfeeding occurs might make it possible to reduce the transmission risk.
Data suggest that 10 – 20 % of babies born to HIV-positive mothers will become infected through breastfeeding when it continues beyond one year. Several factors associated with increased risk of breastfeeding transmission have been identified. Those for which there is strong evidence of increased risk include:
*high maternal HIV load (found in recent infection and in advanced disease)
•clinical symptoms of advanced disease
•immune deficiency (low CD4 and high CD8 counts)
•duration of breastfeeding
•breastfeeding whilst experiencing mastitis, abscesses, or ripple fissures.

Exclusive breastfeeding

Exclusive breastfeeding defined as breastfeeding without any supplementary food or liquid, is generally recommended for the first 6 months of life. It reduces mortality from diarrhoea and respiratory infections and protects against other diseases. Infants who are breastfed exclusively for at least 3 months have significantly lower HIV transmission at 3 and 6 months compared with infants who received breast milk plus other feeds (“mixed feeding”) within the first 3 months of life.
The rate of transmission in exclusively breastfed infants and infants who were never breastfed were similar , 19,4 % at 6 months. In contrast, 26,1 % of infants who were mixed fed are HIV-positive at this age. At 15 months, 24,7% of babies exclusively breastfed for at least 3 months are HIV-infected , compared with 35,9% of the babies who are mixed fed in the early months of life.

Mastitis is a condition resulting from inadequate or poor drainage of milk from the breast. It may be either infectious or non-infectious in origin. Mastitis affects up to a third of breastfeeding women, usually in the first 3 months after delivery. Some vitamin deficiencies may increase the risk of mastitis.
Mastitis can be treated with low-cost antibiotics. Counselling women about good breastfeeding techniques can help them avoid problems that would cause elevated milk sodium, poor milk drainage and inflammation leading to mastitis, as well as nipple problems which may also increase the risk of HIV transmission.

Antiretroviral drug trials for prevention of MTCT

Short-course , prophylactic Antiretroviral drugs (ARV) are the most effective way to reduce MTCT during pregnancy, labour and delivery, and through breastfeeding during the first days of infant life.
It must also be recognised that ARV protocols require the identification of HIV-positive women through voluntary counselling and testing (VCT) services, which need to be expanded in Cameroon.

Recommendations for making breastfeeding safer in the context of HIV

Mothers have a right to information and support so that they can feed their babies safely. They must know their HIV status and they must understand the consequences of each feeding option.
Most of the options for reducing MTCT discussed in this presentation so far only apply to those women who know their HIV status. In Cameroon, however, the vast majority of HIV-infected mothers are unaware of this.
The UN policy is that breastfeeding should be promoted and supported among women who are HIV-negative and those who do not know their HIV status. The following recommendations are therefore made.
•Breastfeeding should begin within 30 minutes of birth
•Breastfeeding skills (Proper position and attachment, how and when to feed the baby ) comfortably) should be established immediately.
•Infants should be fed frequently, ‘on demand’.
•Breastfeeding should be exclusive (no other solids or liquids) for about the first six months.
•Age-appropriate complementary foods should be introduced at 6 months;
•Women at risk of HIV should take steps to avoid infection during the breastfeeding period. (Risk of MTCT is greater immediately after infection because of elevated levels of the virus in the blood).
•Mothers should seek immediate treatment for breast inflammation, cracked nipples or infant mouth sores.
•If such problems occur in one breast only, mothers should express and discard milk from that breast.
These “safer” breastfeeding practices are important for public health programs because they may reduce transmission risks when mothers are:
•unaware of their HIV-status
•HIV-negative but at risk of infection
•HIV-positive but have decided to breastfeed.

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