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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