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Briefing: Malnutrition
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Macronutrients
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Micronutrients
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Targeted Food Assistance
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Learning Points
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References
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See Case 4: Generalized Weakness and Fatigue

Malnutrition is both a cofactor in the progression of HIV disease and a consequence of HIV infection. Infection alters nutrition through changes in intake, malabsorption, and increased metabolism. The malnourished become more immunocompromised, so infections last longer and are more severe.

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Macronutrients
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People living with HIV and AIDS are at increased risk of malnutrition as a result of reduced caloric intake from anorexia and increased metabolic requirements. Immunocompromised patients, even when asymptomatic, need an increase in food intake of up to 400 kcal/day (10-15% increased energy intake), with a minimum consumption of 2,500 kcal/day.(1,2,3) In addition to reduced caloric intake, impaired swallowing from oral and esophageal opportunistic infections, diarrhea from parasitic infections, and HIV enteropathy in advanced disease can lead to decreased intake and malabsorption of fat and carbohydrates.(4,5) Among HIV-infected individuals, poor nutritional status (as assessed by weight loss, low BMI, and low albumin) has been shown to independently predict opportunistic infections, immunologic decline, and shorter survival time in both ART-treated and ART-untreated individuals.(2,6,7) Although most studies have been carried out in developed settings, similar results were reported in a cohort of 1,657 participants from Gambia, where BMI was found to be a strong and independent predictor of survival.(5)

In addition to affecting HIV disease progression, decreased calorie and protein consumption in sub-Saharan Africa is highly correlated with HIV prevalence.(8) HIV transmission is affected by malnutrition in a number of ways. Progressive disability leading to unemployment and difficulties procuring food increase the likelihood of food insecurity for HIV-infected individuals and their families. Food insecurity and malnutrition are thought to increase high-risk sexual behaviors including sex exchange, inconsistent condom use, and multiple partnerships.(9,10) Finally, malnutrition has been associated with antiretroviral nonadherence.(11)

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Micronutrients
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Micronutrients play important roles in maintaining immune function and neutralizing the reactive oxygen intermediates produced by activated macrophages and neutrophils in their response to microorganisms.(12) Serum and plasma measurements of vitamins and trace elements have shown that deficiencies are common among HIV-infected persons, especially women in developing countries. Many of the data on micronutrients and HIV/AIDS have come from observational studies suggesting that the B vitamins, vitamin C, and vitamin E, all potent antioxidants, are associated with reduced risk of HIV progression.(13,14)

Although 2 studies showed that vitamin supplements were associated with improved pregnancy outcomes in women with HIV, vitamin A supplementation has been associated with increased risks in pregnant women with HIV.(15,16) As a consequence, the WHO recommends limited vitamin A supplementation, and only in areas where vitamin A deficiency is endemic.(17) In a study conducted in Thailand, 481 HIV-positive adults were treated with a multimicronutrient supplement or placebo for 48 weeks. There was a 50% reduction in mortality among those on the supplement. This finding was statistically significant only for those with CD4 counts of <200 cells/µL (relative risk = 0.37; p = .05), and there were no effects on HIV viral load or CD4 cell count.(18) Further research is needed to examine the efficacy of multivitamin supplements on reduced disease progression and mortality, especially among patients on ART.

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Targeted Food Assistance
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The absence of randomized controlled trials to examine the benefits of providing food to people living with HIV/AIDS in resource-limited settings reflects the impossibility of conducting such a study in an ethical manner. Therefore, despite the evidence that malnutrition affects disease progression, there are few data on whether food supplementation improves immune function or nutritional status or decreases opportunistic infections, progression to AIDS, or mortality among HIV-infected individuals. Most available data evaluating targeted food assistance programs are from food-secure participants in developed countries.(19,20,21) One of the few prospective studies in a resource-limited setting was an observational study evaluating a home-based care program in Bangwe, Malawi, before the availability of ART. Half of the participants were malnourished and 70% had Stage IV HIV disease at the time of enrollment. There was no difference in survival between those who received food supplementation immediately after enrollment and those who were observed several months before beginning food supplementation. Food supplementation was associated with improved nutritional status, though this improvement was not statistically significant.(22)

The patient in this case receives targeted food assistance from the U.N. World Food Program (WFP) in Uganda. Despite Uganda's fertile soil and growing economy, 38% of its population lives in absolute poverty and a significant portion of the population lacks sufficient access to food.(23) In 2005, the WFP assisted 3.2 million people in Uganda to procure food; 130,000 of those people were HIV/AIDS-affected people, including people on antiretrovirals, people being treated for tuberculosis, HIV-positive pregnant women, and street children and orphans.(24) At the Reach Out clinic in Kampala, more than 1,000 clients are receiving food assistance through the WFP. In addition to improving nutritional status, food supplementation is thought to be an incentive for people to accept HIV testing and counseling.

The WFP aims both to address immediate food needs and to build self-sufficiency. In addition to providing nutritional supplementation, the WFP pairs food distribution with vocation training, education opportunities, and income-generating projects. The WFP provides food aid in the form of "conditional food transfer," whereby clients receive food assistance if they are accessing other services such as primary school education, programs aimed at preventing mother-to-child transmission of HIV, or HIV or tuberculosis care. The WFP also initiated the Food for Assets program, through which clients receive food aid in exchange for participating in "community asset building" projects such as constructing a new school or health care facility. At the same time, the WFP attempts to reduce dependence on food supplementation by supporting local farming. The WFP buys half of the food it supplies in Uganda on the local market (mostly from food commodity traders), and obtained 8% of its local maize purchase in 2005 from small-scale farmers' groups, with the aim of increasing that proportion to 20%.

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Learning Points
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  • Poor nutritional status is strongly associated with progression to AIDS and death among HIV-infected individuals in both resource-sufficient and resource-limited settings.

  • In evaluating HIV-associated weight loss, clinicians must consider malnutrition as well as infectious and metabolic causes.

  • Successful prevention and treatment of malnutrition should address the underlying causes of malnutrition through a combination of medical, nutritional, and financial support to remedy food instability.

  • Community-based programs developed to address the need for food supplementation within HIV/AIDS treatment programs can foster local economic development and reduce reliance on foreign aid and subsidies.

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References

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1.  Eddelston M, Pierini S, Wilkinson R, et al. Oxford Handbook of Tropical Medicine, 2nd edition. New York: Oxford University Press; 2005:603.
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2.   Macallan DC, Noble C, Baldwin C, et al. Energy expenditure and wasting in human immunodeficiency virus infection. N Engl J Med. Jul 13 1995;333(2):83-88.
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3.   Grunfeld C, Pang M, Shimizu L, et al. Resting energy expenditure, caloric intake, and short-term weight change in human immunodeficiency virus infection and the acquired immunodeficiency syndrome. Am J Clin Nutr. Feb 1992;55(2):455-460.
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4.   Babameto G, Kotler DP. Malnutrition in HIV infection. Gastroenterol Clin North Am. Jun 1997;26(2):393-415.
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5.   Stack JA, Bell SJ, Burke PA, et al. High-energy, high-protein, oral, liquid, nutrition supplementation in patients with HIV infection: effect on weight status in relation to incidence of secondary infection. J Am Diet Assoc. Apr 1996;96(4):337-341.
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6.   van der Sande MA, Schim van der Loeff MF, Aveika AA, et al. Body mass index at time of HIV diagnosis: a strong and independent predictor of survival. J Acquir Immune Defic Syndr. Oct 1 2004;37(2):1288-1294.
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7.   Tang AM, Forrester J, Spiegelman D, et al. Weight loss and survival in HIV-positive patients in the era of highly active antiretroviral therapy. J Acquir Immune Defic Syndr. Oct 1 2002;31(2):230-236.
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8.  Stillwaggon E. HIV transmission in Latin America: comparison with Africa and policy implications. S Afr J Econ. 2000:68(5):985-1011.
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9.  Programming in the Era of AIDS: WFP's Response to HIV/AIDS. Rome: World Food Programme; 2003. Available at: http://www.wfp.org/policies/Introduction/policy/index.asp?section=6&sub_section=1#. Accessed September 20, 2006.
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10.  Gillespie S, Kadiyala S. HIV/AIDS and Food and Nutrition Security: From Evidence to Action. Washington: International Food Policy Research Institute; 2005.
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11.   Marston B, DeCock KM. Multivitamins, nutrition, and antiretroviral therapy for HIV disease in Africa. N Engl J Med. 2004; 351: 78-80.
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12.   Semba RD, Tang AM. Micronutrients and the pathogenesis of human immunodeficiency virus infection. Br J Nutr 1999; 81: 181-189.
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13.   Abrams B, Duncan D, Hertz-Picciotto I. A prospective study of dietary intake and acquired immune deficiency syndrome in HIV-seropositive homosexual man. J Acquir Immune Defic Syndr 1993; 6: 949-958.
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14.   Tang AM, Graham NMH, Kirby AJ, et al. Dietary micronutrient intake and risk progression to acquired immunodeficiency syndrome (AIDS) in human immunodeficiency virus type 1 (HIV-1) infected homosexual men. Am J Epidemiol 1993; 138: 937-51.
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15.   Fawzi WW, Msamanga GI, Spiegelman D, et al. Randomised trial of effects of vitamin supplements on pregnancy outcomes and T cell counts in HIV-1-infected women in Tanzania. Lancet 1998;351:1477-1482.
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16.   Fawzi W, Msamanga G, Hunter D, et al. Randomized trial of vitamin supplements in relation to transmission of HIV-1 through breastfeeding and early child mortality. AIDS 2002;16:1935-1944.
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17.  Nutrition Counselling, Care and Support for HIV-Infected Women: Guidelines on HIV--Related Care, Treatment and Support for HIV-Infected Women and Their Children in Resource-Constrained Settings. Geneva: World Health Organization; 2004. Available at: http://www.who.int/hiv/pub/prev_care/en/nutri_eng.pdf. Accessed September 20, 2006.
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18.   Jiamton S, Pepin J, Suttent R, et. al. A randomized trial of the impact of multiple micronutrient supplementation on mortality among HIV-infected individuals living in Bangkok. AIDS 2003; 17: 2461-2469.
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19.   Rabeneck L, Palmer A, Knowles JB, et al. A randomized controlled trial evaluating nutrition counseling with or without oral supplementation in malnourished HIV-infected patients. J Am Diet Assoc. Apr 1998;98(4):434-438.
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20.   de Luis Roman DA, Bachiller P, Izaola O, et al. Nutritional treatment for acquired immunodeficiency virus infection using an enterotropic peptide-based formula enriched with n-3 fatty acids: a randomized prospective trial. Eur J Clin Nutr. Dec 2001;55(12):1048-1052.
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21.   Chlebowski RT, Beall G, Grosvenor M, et al. Long-term effects of early nutritional support with new enterotropic peptide-based formula vs. standard enteral formula in HIV-infected patients: randomized prospective trial. Nutrition. Nov-Dec 1993;9(6):507-512.
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22.   Bowie C, Kalilani L, Marsh R, et al. An assessment of food supplementation to chronically sick patients receiving home based care in Bangwe, Malawi: a descriptive study. Nutr J. Mar 21 2005;4(1):12.
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23.  World Food Programme. World Hunger--Uganda. Available at: http://www.wfp.org/country_brief/indexcountry.asp?region=2&section=9&sub_section=2&country=800. Accessed September 20, 2006.
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24.  WFP to Buy More Local Foods for Distribution. Nairobi: TradeAfrica.biz; 2006. Available at: http://www.tradeafrica.biz/news.asp. Accessed September 20, 2006.
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