Antiretroviral therapy and nutrition interactions
At the end of this section you will be provided with
references older than
2004.
Drain PK, Kupka R, Mugusi F et
al. Micronutrients in HIV-positive persons receiving highly active
antiretroviral therapy. American Journal of Clinical Nutrition, 2007, 85:
333-345.
This article proposes a comprehensive review of available evidence
concerning micronutrients during highly active antiretroviral therapy (HAART).
HIV-positive persons have been shown to have an increased risk of HIV
progression and mortality when a decrease in micronutrients serum is observed.
Among HIV-infected persons without access to HAART micronutrients supplements
can delay disease progression and reduce mortality. While accessibilty to
HAART is growing, the understanding of micronutrients deficiencies and the
role of micronutrients supplements among HIV-positive persons under HAART
remains unclear and has become a priority. The potential benefits of simple
and quite inexpensive micronutrient supplements as an adjunct to HAART may be
valuable. The authors reviewed studies on micronutrient in HAART settings and
point out major limitations. Therefore only few data are available to
determine the real impact of HAART on micronutrients status and the potential
benefits of micronutrients supply to HIV-infected persons receiving HAART. The
authors propose to investigate if HAART initiation restores micronutrients
concentrations independantly of inflammatory markers and whether
micronutrients supply affect HIV outcomes in HIV-infected persons under HAART.
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Heredia A, Davis C, Amoroso A. et al. In
vitro suppression of latent HIV-1 activation by vitamin E: potential clinical
implications: research letter. AIDS. 2005, 19(8): 836-837.
This research letter provides data showing the role vitamin E could play in
reducing the risk of the emergence of drug resistant HIV-1 variants in
patients undergoing antiretroviral treatment interruption.
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Jones CY, Tang AM, Forrester JE et al.
Micronutrient levels and HIV disease status in HIV-infected patients on highly
active antiretroviral therapy in the Nutrition for Healthy Living cohort.
Journal of Acquired Immune Deficiency Syndrome. 2006, 1, 43(4): 475-482.
Before the introduction of higly active antiretroviral therapy (HAART), low
serum micronutrients levels were common. These deficiencies have been
associated with adverse outcomes. This cross sectional study intended to
investigate in HIV-infected persons on HAART the prevalence of low serum
levels of retinol, alpha-tocopherol, zinc, and selenium; whether low levels of
these micronutrients are associated with worse HIV disease status; and also to
understand if supplementation is associated with better HIV disease status.
Blood samples from 117 HIV-infected women and 171 men from the Nutrition for
Healthy Living (NFLH) study were analysed. CD4 cell counts, CD4 count <200
cells/mm, viral load, and undetecteble viral load were assessed. Except mainly
for zinc there was a low prevalence of micronutrient deficiency. Women in the
upper quartiles of zinc had significantly lower log viral load levels than
those in the lowest quartile. The same trend was observed for women and men
for selenium. Women in the upper quartiles of retinol had higher log viral
loads than those in the lowest quartile. There was no statistical association
of any micronutrient with CD4 cell count or likelihood of CD4 count <200
cells/mm. Among men with CD4 counts >350 cells/mm, those with higher retinol
had higher log viral loads compared with the lowest quartile, whereas it was
the opposite for men with CD4 counts <350 cells/mm. It appears that low
retinol, alpha-tocopherol and selenium are uncommon in HIV-infected adults on
HAART. Zinc deficiency seems to be more common. Decreased serum retinol levels
in women and in men with CD4 counts >350 cells/mm as well as increased serum
zinc levels in both genders were associated with improved virologic control.
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Mangili A, Murman DH Zampini AM et al.
Nutrition and HIV infection: review of weight loss and wasting in the era of
highly active antiretroviral therapy from the nutrition for healthy living
cohort. Clinical Infectious Diseases, 2006, 42: 836-842.
Wasting and weight loss remain common problems among HIV-infected persons
and their etiology is complex and multifactorial. Weight loss also remains an
independent predictor of mortality and is associated with lower CD4+ cells
counts. The authors discuss evidence of the Nutrition for Healthy Living (NFHL)
cohort, a longitudinal cohort including 881 HIV-infected adults from Boston
(US) area between 1995 and 2005. Mean age was 40 years and half of the cohort
was receiving Highly Active Antiretroviral Therapy (HAART). The authors focus
on nutritional status, weight loss and wasting in the present clinical era.
They summarize some practical elements concerning weight loss and wasting in
HIV setting. The etiology of weight loss is reviewed in 2 main categories:
inadequate nutrient intake and altered metabolism. Finally a summary of
studies addressing weight loss in HAART era is provided. Points addressed here
aim to raise awereness of the remaining problem concerning weight loss and
wasting in HAART era.
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Marston B, De Cock KM. Multivitamins, nutrition, and antiretroviral
therapy for HIV disease in Africa. New England Journal of Medicine, 2004,
351:78-80.
Up to now there have been little studies with extensive use of
multivitamins supplementation in Africa, and long term vitamin administration
has not been considered relevant. Even in the industialized world the authors
notice a lack of solid data regarding the value of multivitamins
supplementation, although routine supplementation is often practiced. This
editorial paper calls for evaluation of multivitamins supplementation in large
populations with access to antiretroviral therapy (ARV), and particulary among
persons with advanced HIV disease or with serious nutritional deficiencies.
According to a study published in the same issue of the New England Journal of
Medicine micronutrients supplementation could be a way to delay the need to
institute ARV, and therefore saving resources as well as preserving
therapeutic options. In this way multivitamins would offer safe opportunities
for patients to become accustomed to taking regular medication before
beginning ARV. This article also explores the role of HIV/AIDS in food
insecurity in Africa. It ends with a recommendation to develop innovative
schemes to address the need for food supplementation within HIV/AIDS treatment
programmes.
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the entire article.
McComsey GA, Leonard E. Metabolic complications of HIV therapy in children.
AIDS, 2004, 18(13): 1753–1768.
Survival of HIV-infected children has greatly improved with the
introduction of highly active antiretroviral therapy. Children are particulary
vulnerable to the long term adverse effects of antiretroviral therapy because
of its potential impact on growth and children are likely to have greater
cumulative exposure. Therefore, this review article examines metabolic
complication associated with antiretroviral therapy in children, and topics
such as lipodystrophy, dyslipidemia, insulin resistance, mitochondrial
toxicity and bone diseases are covered.
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Montessori V et al. Adverse effects of antiretroviral therapy for HIV
infection. Canadian Medical Association Journal, 2004, 170(2):229–238.
Antiretroviral therapy can have a wide range of adverse effects on the
human body. This review article explores the short-term and long-term adverse
effects of antiretroviral therapy. Common but mild adverse effects occurring
early in most antiretroviral regimens include gastrointestinal effects such as
bloating, nausea and diarrhea, which may be transient or may persist
throughout therapy. The purpose of this article is to discuss about the subtle
and serious nature of other adverse effects that are directly linked to
nutrition, like osteoporosis, hyperglycemia, and fat maldistribution. Although
current antiretroviral regimens are potent from an antiviral perspective, they
often fail because of patient nonadherence. To optimize adherence, clinicians
should focus on preventing adverse effects when possible. This article is
intended to help make the distinction between the side effects that are
self-limited from those that are potentially serious.
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entire article.
Mwanburi MD et al. Understanding the
role of HIV load in determining weight change in the era of highly active
antiretroviral therapy (HAART). Clinical Infectious Diseases, 2005, 40:167-173.
The aim of this study was to establish the relationship between HIV RNA load
and weight change among HIV infected individuals. This study is part of the
Nutrition for Healthy Living Study which investigates the role of nutrition in
HIV disease. 318 participants were included in this cohort based study. 54% of
the participants were under HAART at the time of enrollment and most were men
(81%). The authors found that in the absence of HAART, virus load strongly
influenced weight loss. They found that it was not the case for HAART-receiving
patients. The finding that change in virus load, rather than change in CD4 cells
counts, predict weight loss in patients who are not taking HAART implies that
virus load suppression is a necessary condition for control of weight loss.
Therefore the authors propose that patients who are losing weight and not taking
HAART should start taking HAART to prevent more weight loss. Finally they call
for further research in examining resting energy expenditure in patient taking
HAART and in those who are not receiving HAART.
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the entire article.
Patton NI, Sangeetha S, Earnest A et al. The impact of malnutrition on
survival and the CD4 count response in HIV-infected patients starting
antiretroviral therapy. HIV Medicine. 2006, 7: 323-330.
Treatment of HIV-infected patients with antiretroviral therapy (ART) leads
to immune reconstitution as shown by the increase in CD4 counts, decreased
risk of opportunistic infections and improved survival. The response to
treatment however, is not uniform. This article aims to investigate the impact
of malnutrition at the time of starting ART on survival and CD4 count
response. The authors used retrospective data from a cohort of Singaporean
patients with CD4 counts of less than 250 cells/μL and starting ART. Body mass
index was recorded and moderate to severe malnutrition was defined as BMI of
less than 17kg/m². 394 patients were included in the analysis, median
follow-up was 2.4 years. Moderate to severe malnutrition was present among 16%
of patient at the time of starting ART, and was a significant predictor of
death. The stage of the disease and the type of ART (Highly Active
Antiretroviral Therapy (HAART) versus non HAART) were also significant
independent predictor of death. Malnutrition did not impair the magnitude of
the increase in CD4 count at 6 or 12 months. Therfore it appears that
malnutrition at the time of starting ART is significantly associated with
increased mortality, but the effect seems to be independent of the impaired
immune reconstitution. As there is increasing access to ART in developing
countries and a high prevalence of HIV-associated wasting, the authors call
for studies of nutritional therapy as an adjunct to the initiation of HAART.
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RCQHC/FANTA/LINKAGES projects/USAID.
Food and nutrition counseling for PLWHA on antiretroviral therapy: A job aid for
counselors and antiretroviral therapy service providers. Kampala, Regional
Centre for Quality of Health Care, 2004.
The aim of this publication is to provide guidance for health care workers,
counselors, and antiretroviral therapy service providers in the field of
antiretroviral therapy and nutrition interactions. The document is prepared for
different uses: first, to understand the food and nutrition implications of drug
regimens; second, to identify appropriate and possible nutrition actions to
promote effective treatment, ensure adherence to drug regimens, manage side
effects, and minimize negative effects on nutritional status; and third to
implement the best nutrition actions and make necessary adjustments to dietary
practices.
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Raiten DJ, Grinspoon S, Arpadi S.
Nutritional considerations in the use of ART in resource-limited settings.
Consultation on Nutrition and HIV/AIDS in Africa: Evidence, lessons and
recommendations for action. Durban, South Africa, 10-13 April 2005. Geneva,
World Health Organization, 2005.
This technical report reviews the evidence about the importance of diet and
nutritional status to pharmacology in general and the potential interaction
between HIV status and current treatment for HIV and related conditions. The
authors analyse current knowledge on metabolic consequences of HIV/AIDS before
and after antiretroviral therapy. Then in relation to nutrition they examine
the different metabolic consequences and complications of the treatments.
Gender, and infant and child issues are also examined. However, what has
emerged from the limited number of studies is that a real potential exists for
the interactions between treatment and food, and that people living with
HIV/AIDS need to receive appropriate counselling to ensure safe and
efficacious delivery of drugs. The paper ends with a brief listing of topics
requiring further research.
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for the entire article.
Tang AM, Jacobson DL, Spiegelman D et
al. Increasing risk of 5% or greater unintentional weight loss in a cohort of
HIVinfected patients, 1995 to 2003. Journal of Acquired Immune Deficiency
Syndrome. 2005, 40: 70–76.
Even though Highly Active Antiretroviral Therapy (HAART) has improved
quality of life among HIV-positive persons, weight loss and wasting remain
common. Some studies have shown that among HIV-positive persons 5% weight loss
in 6 months is markedly associated with an increased risk of death. The author
examined the 6 month risk and determinant of 5% or more weight loss during a
period from 1995 to 2003 when combination of antiretroviral therapy and HAART
was common in the United States. Data from 713 participants enrolled in the
Nutrition for Healthy Living cohort were explored. There was a significant
increase (p=.002) in the 6 month risk of 5% or more weight loss in the later
years (1998-2003) than in the early years (1995-1997). Some other variable
like poverty, high body mass index (>25kg/m²), lower CD4 cell count, higher
viral load and presence of diarrhea, nausea or fever were significantly
independently associated with risk of 5% or more weight loss. It seems that
weight loss is on the rise in this cohort despite better control of HIV
infection. The results shown here indicate the need to continue to pay
attention to weight loss among some specific HIV-positive person.
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Volberding PA et al. Anemia in HIV infection: clinical impact and
evidence-based management strategies. Clinical Infectious Diseases, 2004,
38(10):1454-1463.
This article, drafted from a expert group consensus, summarizes
evidence-based treatment guideline for anaemia in HIV/AIDS. The document tells
about the serious implications of anaemia in HIV-infected patients, which vary
from functional and quality-of-life decrements to an association with disease
progression and decreased survival. The expert group reached consensus on the
prevalence of anaemia in the highly active antiretroviral therapy era; the
risk factors that are independently associated with the development of anaemia;
the impact of anaemia on quality of life, physical functioning, and survival;
the impact of the treatment of hepatitis C virus coinfection on anaemia in
HIV-infected patients. This article proposes finally a guideline for treatment
of anaemia in HIV-infected patients; and directions for future research.
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NEW! Volmink J, Siegfried NL, van der Merwe L
et al. Antiretrovirals for reducing the risk of mother-to-child transmission of
HIV infection. Cochrane Database Systematic Review. 2007 Jan 24;(1):CD003510.
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NEW! WHO. Management of HIV Infection and
Antiretroviral Therapy in Adults and Adolescents - A Clinical Manual. Geneva,
World Health Organization, 2007.
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WHO. Nutrition and HIV/AIDS. Geneva,
World Health Organization, 2005.
The Health Assembly, in resolution WHA57.14, called for integration of
nutrition into a comprehensive response to HIV/AIDS. This document is the
statement of the WHO consultation on nutrition and HIV/AIDS in Africa that took
place in Durban in April 2005. It proposes guidance for different nutrition
topics such as: macronutrients, micronutrients, pregnancy and lactation, infant
and young child feeding, interaction between nutrition and antiretroviral
therapy. It ends with recommendations for action, and stresses on nutrition as
an integral part of the response to HIV/AIDS in Africa.
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here for the entire article.
The goal of the consultation is available here.
In this section you will find documents older than 2004:
Barrios A et al. Effect of dietary intervention on highly active
antiretroviral therapy-related dyslipemia. AIDS, 2002, 16(15):2079-2081.
In this trial, the authors assessed the changes in cholesterol and
triglyceride levels after prescribing a lipid-lowering diet in 230
HIV-infected patients with dyslipemia due to antiretroviral therapy. Lipid
levels decreased significantly in subjects having good diet compliance. The
reduction in triglyceride levels was greater than in cholesterol levels.
Patients on protease inhibitor-containing regimens experienced a slightly
greater decline in lipid levels compared with the rest.
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Castleman T, Seumo-Fosso E, Cogill B. Food and nutrition implications of
antiretroviral therapy in resource limited settings. Washington, DC, FANTA
Project, 2003.
This document provides information and guidance about the food and
nutrition implication of the antiretroviral therapy (ARV), and explain how to
minimize the effects on food consumption. The aim of this document is to
assist program planners, group developing guidance on care and support,
service providers, and networks of people living with HIV/AIDS to understand
and address antiretroviral therapy interaction with food and nutrition. It
also provides information on this implications of ARV on food consumption and
on nutritional management of side effects of ARV. Managing the interactions
between antiretroviral therapy and food and nutrition is a critical factor in
the extent to which the therapy is effective in delaying the progression of
the disease. It also contribute to improve the quality of life of people
living with HIV/AIDS. In some countries the access of food in quality and
quantity is lacking, that poses additional challenges to the success of the
therapy. This technical note summaries information on the different ARV
commonly used in resource limited settings and on interactions between them
and nutrition. It also gives information.
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here for the entire article.
Dube M, Fenton M. Lipid abnormalities. Clinical Infectious Diseases, 2003,
36(S):79-83.
According to different studies, about 50% of HIV infected individuals
receiving protease inhibitors present lipid abnormalities (including elevation
of low-density lipoprotein cholesterol or decrease of high-density lipoprotein
cholesterol or hypertriglyceridemia). Therfore, dyslipidemia is a common
problem among HIV-infected individuals receiving antiretroviral treatment, and
data suggesting a higher cardiovascular risk in this population are present.
This paper provides a guideline, with evidence based articles, on the way to
treat dyslipidemia. It stresses that the first interventions must be
non-pharmacological and should include nutrition, exercice, and managment of
other hygienic factors. The drug therapy should only be used when the dietary
and lifestyle interventions are not satisfactory, and limited to agents with
the least likelihood of adverse drug interactions.
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Dube MP et al Guidelines for the evaluation and management of dyslipidemia
in human immunodeficiency virus-infected adults receiving antiretroviral
therapy: Recommendations of the HIV Medicine Association of the Infectious
Disease Society of America and the Adult AIDS Clinical Trials Group. Clinical
infectious diseases, 2003, 37(5):613-627.
These guidelines provide information on the management of dyslipidemia in
HIV infected adult receiving antiretroviral therapy, including nutritional
treatment, but focusing on drug therapies. Dyslipidemia is a common problem
affecting HIV infected patients receiving antiretroviral therapy. The
implications of dyslipidemia in this population are not fully known,
preliminary data indicate increased cardiovascular morbidity among
HIV-infected individuals, suggesting that measures to reduce cardiovascular
risk should be provided. The authors of the guidelines recommend that
HIV-infected adults undergo evaluation and treatment on the basis of the
National Cholesterol Education Program Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol in Adults NCEP ATP III guidelines for
dyslipidemia, with particular attention to potential drug interactions with
antiretroviral agents and maintenance of virologic control of HIV infection.
Nondrug therapies, including nutritional treatment, should generally be
instituted first and given a thorough trial before instituting drug therapies,
except when there is an urgent need to intervene. When drugs become necessary,
the present guideline presents recommendations.
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Miller TL. Nutritional aspects of HIV-infected children receiving highly
active antiretroviral therapy. AIDS, 2003, 17(S1):130-140.
The presentation of the nutritional problems of HIV-infected children is
changing over time with improved antiretroviral regimens. In the facts the
incidence of malnutrition in developed countries has decreased with highly
active antiretroviral therapy, a significant number of patients still have
problems with malnutrition and gastrointestinal dysfunction, and some are
developing insulin resistance and truncal obesity. This article presents datas
on the wasting syndrome, on the causes of malnutrition, on the nutritional
effects of antiretroviral therapies, and on the nutritional intervention
strategies for HIV-infected children.
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Mondy K, Tebas P. Emerging bone problems in patients infected with human
immunodeficiency virus. Clinical Infectious Diseases, 2003, 36(S2):101-105.
This article focuses on the relationship between bone abnormalities and
other complications associated with HIV and antiretroviral therapy. The
incidence of osteopenia and osteoporosis seems to grow in HIV infected
individuals. This problem appears to be linked with antiretroviral therapy.
Other bone-related complications have also been reported, but the underlying
mechanisms remain unknown. The authors propose that HIV-infected patients with
osteopenia or osteoporosis should be treated similarly to HIV-seronegative
patients with appropriate use of nutritional supplements, including calcium
and vitamin D, and exercise. The authors finally suggest that hormone
replacement and antiresorptive therapies might to be useful.
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Schambelan M et al. Management of metabolic complications associated with
antiretroviral therapy for HIV-1 infection: Recommendations of an international
AIDS society -USA panel. Journal of Acquired Immune Deficiency Syndromes, 2002,
31:257-275.
This document is the result of the work of a panel of experts working in
the field of HIV patient care, antiretroviral therapy, and endocrinology and
metabolic disorders. The article proposes a guideline for the assessment and
the management of metabolic complication of antiretroviral therapy. It
presents information for the major complications of antiretroviral therapy,
including: insulin resistance and abnormal glucose homeostasis, lipid and
lipoproteins metabolism abnormalities, body fat distribution abnormalities,
lactic academia, and bone disease. Most of the complications have nutritional
consequences, and for some a brief section on diet therapy is provided. The
major concluding recommendation of the report are summarized in one table.
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