Delaying progression of HIV to AIDS using nutrition management
At the end of this section you will be provided with
references older than
2004.
Arpadi SM. Growth failure in HIV-infected children 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 document is issued from a WHO consultation on nutrition and HIV/AIDS
that took place in Durban, South Africa in April 2005. Poor growth is common
in HIV-infected children and has a significant adverse effect on survival
independent of the degree of immune deficiency. The causes of growth failure
is multifactorial and a wide review of growth in the context of HIV/AIDS is
proposed. This includes: 1 - the prevalence of growth abnormalities, 2 -
intrauterine growth, 3 - infant and child growth in the context of HIV/AIDS, 4
- the association between fat-free, lean body mass and growth failure, 5 -
growth, body composition and survival, 6 - etiology of growth failure, 7 -
studies of energy balance and viral replication, 8 - neuroendocrine disorders
and growth, 9 - HIV, diarrhea, malabsorption and growth, 10 - the effects of
antiretroviral therapy on growth, 11 - the effects of psychosocial aspects on
growth are also taken into account. Results of studies also suggest that
prevention, early detection and treatment of diarrhoeal illnesses may be
effective targets for enhancing childhood growth and survival in children with
HIV. The author ends with a list of research gaps and programmatic challenges
and considerations.
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for the entire article.
Austin J, Singhal N, R Voigt et al. A community randomized controlled
clinical trial of mixed carotenoids and micronutrient supplementation of
patients with acquired immunodeficiency syndrome. European Journal of Clinical
Nutrition, 2006, 60: 1266–1276.
This prospective double blind placebo controlled trial investigated the
impact of carotenoids supplements on survival and health of AIDS patients. 331
adults with advanced AIDS on conventional management were recruited during
routine clinic visits. 166 persons were recruited to act as control. All
participants received daily oral multivitamins including vitamin A and trace
elements. Half of the patients received an additional daily oral natural mixed
carotenoids, equivalent to 120 000 IU (72 mg) of beta carotene daily. Follow
up was quarterly at routine clinic visits. Mean duration of follow-up was 13
months. 36 participants died by 18 months. Serum carotene concentration <1,0
mol/l was present in 16% participants at baseline. After 18 months and
compared to controls, serum carotene concentration increased significantly to
twice the baseline levels among participants who received carotenoids
(p<.0001). The mortality was increased in participants who did not received
carotenoids treatment compared to those who did, but this trend was not
significant (p=.11). However in multivariate analysis survival was
significantly and independently improved in those with higher baseline serum
carotene concentration (p=.04) or higher baseline CD4 T lymphocyte counts
(p=.005). It seems that low serum carotene concentration is common in AIDS
patients and can predict death among advanced AIDS patients. Supplementation
as used here may correct micronutrient deficiency and improve survival. This
finding needs to be confirmed and the mechanism of action still need to be
clarified.
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Batterham MJ. Investigating
heterogeneity in studies of resting energy expenditure in persons with HIV/AIDS:
a meta-analysis. American Journal of Clinical Nutrition, 2005, 81 (3): 702.
There is conflicting data on resting energy expenditure (REE) in HIV/AIDS
infected individuals, and up to now the differences reported have not been
cleared. This meta analysis aimed to ascertain the potential difference in REE
between HIV positive persons and healthy control persons. The author wanted as
well to explore the possible variation of REE in some various clinical subgroup,
such as individual with lipodystrophy, or those who are losing weight, or
asymptomatic, or even those with stable weight. 58 studies reached the inclusion
criteria. After analysis it occurs that REE is significantly higher in HIV
infected persons than in the healthy control group. The subgroup analysis
proposes that persons with symptomatic infection have significantly elevated REE
comparing to other HIV subgroup, and other conclusions for different subgroups
are not available because of a lack of significant data. Finally the author
calls for further research to investigate the effect of highly active
antiretroviral therapy on REE in HIV.
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Centeville M, Morcillo AM, de Azevedo Barros Filho A et al. Lack of
association between nutritional status and change in clinical category among HIV
infected children in Brazil. Sao Paulo Medicine Journal, 2005, 123(2): 62-65.
This longitudinal retrospective study aimed to investigate the occurrence
of malnutrition and its relationship with changes in clinical category among
HIV-infected children. Hospital records of 127 vertically infected children
were reviewed. The authors obtain anthropometric data at the beginning of the
follow-up, at clinical category change and five months later. Children were
classified according to the pediatric Center for Disease Control AIDS
classification from 1994. The children were also organized in categories for
stunting and wasting. In conclusion, the authors found that the severity of
the manifestation of AIDS was associated with nutritional status and with age
at symptom onset. They also noted that the change in clinical category was not
followed by a change in nutritional status. This article reinforce the link
between nutritional status and clinical progression of HIV/AIDS.
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the entire article.
Coyne-Meyers K, Trombley LE. A Review of
Nutrition in Human Immunodeficiency Virus Infection in the Era of Highly Active
Antiretroviral Therapy. Nutrition in Clinical Practice, 2004, 19(4):340-355.
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here for summary.
Crenn P et al. Hyperphagia contributes to the normal body composition and
protein energy balance in HIV-infected asymptomatic men. Journal of Nutrition,
2004, 134 (9):2301-2306.
Wasting can occur at an early stage of HIV infection. Wasting is defined as
reduced energy intake and increased resting energy expenditure, with a
predominant loss of lean body mass and suggesting disturbance of protein
metabolism. The aim of this experiment was to study protein-energy metabolism
in relation to body composition and oral energy intake in asymptomatic
patients with HIV receiving no active antiretroviral therapy. Stable-weight
asymptomatic male patients were compared with 9 healthy control men. Protein
metabolism was studied in the postabsorptive state. Resting energy expenditure
was studied by indirect calorimetry, body composition by bioelectrical
impedance, and energy intake by dietary records. Body mass index and lean body
mass did not differ between patients and controls. In HIV-infected subjects,
energy intake, protein breakdown, protein synthesis, and REE were greater than
in controls. Resting energy expenditure and protein breakdown were correlated.
At the asymptomatic stage of HIV infection, increased protein turnover seems
contributing to the increase of the resting energy expenditure. It occurs that
moderate hyperphagia should maintain a normal body composition, without
significant loss of lean body mass.
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FANTA Project. HIV/AIDS: A Guide For Nutritional Care and Support.
Washington, DC, The FANTA project, 2004.
This guide provides and popularizes information for HIV/AIDS affected
households and communities on how nutrition can help HIV-infected individuals
live healthier throughout the progression of the HIV disease. It is well
admitted that malnutrition plays a significant and independent role in HIV
infection's morbidity and mortality. Malnutrition was one of the earliest
complications of AIDS to be recognized and has been used to clinically
diagnose AIDS. The links between HIV/AIDS and nutrition are still to be
studied. Research does suggest that the chance of HIV-infection might be
reduced in individuals who have good nutritional status; the onset of the
disease and death might be delayed where HIV-infected individuals are
well-nourished; and nutrient-rich diets might reduce the risks of HIV
transmission from mother to fetus or baby during pregnancy or birth. This
guide is an interpretation of the latest available evidence to date from
multiple sources, especially the World Health Organization, and a broad range
of experts. The purpose of this guide is to assist programme managers and
health workers make recommendations. The guide is divided into 6 parts:
1)Nutrition and HIV/AIDS: Basic Facts, 2) Managing HIV Disease Through
Nutrition Interventions, 3) Nutritional Issues Associated With Modern and
Traditional Therapies, 4) Nutritional Care and Support for Pregnant and
Lactating Women and Adolescent Girls, 5) Nutrition and Care Recommendations
for Infants and Children, 6) A Food-based Approach to Support
HIV/AIDS-affected Households and communities
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fanta@aed.org
NEW! FAO. AIDS and your food. Rome, Food and
Agriculture Organization.
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the entire article.
Fawzi WW, Msamanga GI, Kupka R et al.
Multivitamin supplementation improves hematologic status in HIV-infected women
and their children in Tanzania. American Journal of Clinical Nutrition, 2007,
85(5): 1335-1343.
Anemia is a frequent complication among HIV-infected persons and is
associated with various adverse outcomes. Iron supplementation has been shown
to raise hemoglobin concentrations, and treatment and prevention of infections
are other important intervention to control anemia. Despite the widespread
implementation of these interventions, anemia remains a major problem.
According to the authors no study have yet assessed the efficacy of
multivitamins alone in African settings where HIV infection, malaria and other
infectious diseases are prevalent. This study aims to examine the efficacy of
maternal supplementation during pregnancy and after delivery on hemoglobin
concentrations and the risk of anemia among the women and their children.1078
HIV-infected pregnant women from Dar es Salaam in Tanzania were enrolled in a
double-blind placebo-controlled trial. Participants were not receiving
antiretroviral treatment and received daily either vitamin A alone,
multivitamins (b-complex, vitamin C and E but excluding vitamin A),
multivitamin plus vitamin A or placebo. All women received iron and folate
supplement only during pregnancy according to local standard of care.
Hemoglobin measurement and investigation and treatment for parasites occurred
every 6 months. 906 women had at least 2 measurement and therefore were
included in the analysis. Median follow-up time for hemoglobin measurement for
mothers was 57,3 months (28,6-66,8) and for children it was 28 months
(5,3-41,7). The different arms of the trial were not significantly different
according to mean age and gestational age at enrollment. Other baseline
characteristics were also similar. Compared with placebo, multivitamin
supplementation resulted among women in a hemoglobin increase of 0,59 g/dL
during the first 2 years after enrollment (p=.0002). Compared to placebo
group, the children born to mothers who received multivitamins had a 63%
reduced risk of anemia (RR=0,37, 95% CI: 0,18, 0,79, p=.01). Multivitamin
supplementation provided during pregnancy and in the postpartum period
resulted in significant improvements in hemoglobin status among HIV-infected
women and their children.
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Fawzi WW et al. A randomized trial of multivitamin supplements and HIV
disease progression and mortality. New England Journal of Medicine, 2004,
351(1):23-32.
The authors compared supplementation consisting of multivitamins alone,
vitamin A alone, or both with placebo. They found that women who were randomly
assigned to receive multivitamin supplementation were less likely to have
progression to advanced stages of HIV disease, had better preservation of CD4+
T-cell counts and lower viral loads, and had lower HIV-related morbidity and
mortality rates than women who received placebo. Vitamin A appeared to reduce
the effect of multivitamins and, when given alone, had some negative effects.
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Fawzi WW et al. Studies of vitamins and
minerals and HIV transmission and diseases progression. Journal of Nutrition,
2005, 135:938-944.
This article is part of a symposium that took place in April 2004 in
Washington, DC. It presents a review of evidence about the effects of
micronutrients (vitamins and minerals) supply on HIV transmission and
progression. It reviews trials that have been undertaken in resource limited
setting and in developed countries, and reviews separately vitamins and minerals
(merely selenium and zinc). Finally, the authors provide some comments on the
studies, classifying them in different sections: vitamin A among children,
vitamin A among adults, and multivitamin supplement during pregnancy and
lactation. Authors warn about the use of micronutrient supplementation as an
alternative treatment, instead recommend micronutrient supplementation as a
complementary intervention to antiretroviral therapy (ART). They finish with a
call for further research in the field of other micronutrient supplementation
among adults who are advanced in their disease and are receiving ART therapy and
among children.
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Jiamto S, Chaisilwattana P, Pepin J et
al. A randomized placebo-controlled trial of the impact of multiple
micronutrient supplementation on HIV-1 genital shedding among Thai subjects.
Journal of Acquired Immune Deficiency Syndrome, 2004, 37(1):1216-1218.
This randomized placebo controlled trial aimed to investigate the impact of
multiple micronutrients supplementation on HIV genital shedding among men and
women. Participants were engaged in a bigger cohort study. The authors
recruited 140 consecutive participants from the main study, all of them were
antiretroviral naive, and had CD4 cells count between 50-550 cells/mm³. The
subjects were randomly allocated to multiple micronutrients supplements (n=71)
or placebo (n=69). Baseline characteristics were similar between the two arms.
Genital, cervicovaginal and plasma HIV viral load was tested. Plasma viral
load was correlated with seminal viral load (r=0.44; p.0003, n=65) but not
with cervicovaginal secretions (r=0.18; p=.01, n=71). After 48 weeks of
follow-up, the median CD4 cell count, mean log viral load in plasma, semen and
cervicoaginal secretions did not differ significantly between patients in both
group (p>.4 for each comparison). The percentage changes from baseline to end
of follow-up did not differ between the 2 groups. It seems that multiple
micronutrient supplementation have no impact on viral load in seminal or
cervicovaginal secretions.
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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, 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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Kaiser JD, Campa AM, Ondercin JP et al.
Micronutrient supplementation increases CD4 count in HIV-infected individuals on
highly active antiretroviral therapy: A prospective, double-blind,
placebo-controlled trial. Journal of Acquired Immune Deficiency Syndrome, 2006,
42 (5): 523-528.
This prospective double blind placebo controlled trial aims to investigate
the effects of micronutrient supplementation among HIV-positive person
receiving Highly Active Antiretroviral Therapy (HAART). 40 HIV-infected
persons under a stavudine and/or didanosine based HAART treatment were
randomized to receive micronutrients or placebo twice daily for 12 weeks.
Immunologic, metabolic and clinical measurement were collected monthly. Main
outcome consisted of immunologic parameters and secondary end points were
metabolic and clinical effects, and distal symmetrical polyneuropathy. At the
end of the follow up mean CD4 cells count increased in the supplementation
group versus the placebo group (+65 cells vs -6 cells, p=.029). The absolute
CD4 count increased by an average of 24% in the micronutrient group versus no
change in the other group (p=.01). Neuropthy scores improved in the
micronutrient group by 42% compared with a 33% improvement in the other arm,
but the difference was not significant. Serum parameters were not different
among both groups. Micronutrients supply as proposed here seems to improve CD4
cells count reconstitution in HIV-infected person taking HAART.
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Kruzich LA et al. US youths in the early stages of HIV disease have low
intakes of some micronutrients important for optimal immune function. Journal of
the American Dietetic Association, 2004, 104(7):1095-1101.
The authors studied, in a cross sectional study using the Block Food
Frequency Questionnaire (version 98.2), the association between micronutrients
intake and HIV infection in adolescents and young adults. 264 HIV-infected and
127 non-infected participants were included. The study showed inadequate
intake of vitamin A and E and zinc in the population. In addition the
HIV-infected youth may have increased micronutrient needs related to impaired
immune function and metabolic complications of the disease. Finally, the
authors appeal for more research to determine the micronutrient needs for
HIV-infected youths.
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Kupka R et al. Selenium status is associated with accelerated HIV disease
progression among HIV-1-infected pregnant women in Tanzania. Journal of
Nutrition, 2004, 134(10):2556-2560.
Selenium state has been implicated in HIV disease progression and appears
to poorer survival among populations infected with HIV in developed countries.
This study examined these relations in a developing country, Tanzania. Among
949 HIV-infected pregnant women, the authors looked at the association between
plasma selenium levels and survival and CD4 counts over time. Over the
5.7-year median follow-up time, 306 of 949 women died. In a Cox multivariate
model, lower plasma selenium levels were significantly associated with an
increased risk of mortality. Increased plasma selenium levels was related to a
decreased risk of mortality. Plasma selenium levels was not associated with
time to progression to CD4 cell count < 200 cells/mm, but were weakly and
positively related to CD4 cell count in the first years of follow up.
According to the authors, selenium status seems to be important for clinical
outcomes related to HIV disease in Sub-Saharan Africa.
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LINKAGES/FANTA/SARA/RCQHC/USAID. Women's
nutrition throughout the life cycle and in the context of HIV/AIDS. Washington,
DC, The LINKAGES project, 2005.
This module is intended to equip instructors with basic theory to train
health workers. It explores issues regarding women's nutrition throughout the
life cycle. The first chapters focuses on nutrition needs for specific non
HIV/AIDS situations. The second part of it is developed for the HIV/AIDS
context. It addresses the synergetic relationship between nutrition and HIV
infection, the nutritional requirement of HIV-positive pregnant and lactating
women and adolescent girls, and nutritional care and support of HIV-infected
women. The document is based on "the Guidelines on Maternal Nutrition during
Pregnancy and Lactation within the Context of HIV and AIDS" developed by the
Republic of South Africa Department of Health Directorate of Nutrition.
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Ministry of Health - Uganda. Nutritional Care and Support for People
Living with HIV/AIDS in Uganda: Guidelines for Service Providers. The Republic
of Uganda, 2004.
The purpose of these guidelines is to define the actions that service
providers need to undertake in order to provide quality care for and support
to HIV-infected individuals at various contact points including voluntary
counseling and testing, antenatal care, postnatal care, community visits,
home-based care, agricultural extension, and education. The guideline seeks to
assist the different categories of HIV/AIDS infected or affected people: men,
pregnant and lactating women, adolescents, young children, severely
malnourished children, food insecure households. A section providing
information about food and drug interactions is also available in this
document.
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NFNC. Nutrition guideline for care and
support of people living with HIV/AIDS. Lusaka, Zambia, National Food and
Nutrition Commission, 2004.
This complete guideline, adapted for Zambia and may be used by surrounding
countries, is intended to support with useful and practical information those
who take care of people living with HIV/AIDS. The document gives general
information on nutrition and also more technical information that link nutrition
and HIV/AIDS. It also provides guidance for nutrition support during home based
care for people living with HIV/AIDS. The guideline develops specific sections
on nutritional care for pregnant women, and for infants born to HIV-infected
mothers. Sections concerning antiretroviral therapy, food safety, and food
security are also mentioned.
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O'Brien ME, Kupka R, Msamanga GI et al.
Anemia is an independent predictor of mortality and immunologic progression of
disease among women with HIV in Tanzania. Journal of Acquired Immune Deficiency
Syndrome. 2005, 40(2): 219-225.
Anemia is the most frequent hematologic complication during HIV, and the
prevalence of anemia among African women with HIV infection have been reported
to be approximately 70-80%. Given this and the fact that few studies have
examined the association of anemia with mortality and HIV progression among
women in sub Saharan Africa, the authors intended to examine this association
among a cohort of Tanzanian women. 1078 pregnant women with World Health
Organisation (WHO) clinical stage 1 or 2 disease were enrolled into the trial.
According to local guidelines, they received iron and folate for antenatal
care. They were randomized to receive one of the following regimen:
multivitamins (B complex, C and E), vitamin A plus beta-carotene,
multivitamins that included vitamin A plus beta carotene, or placebo.
Hematologic exams were provided at baseline, 6 weeks and 30 weeks postpartum,
and every month thereafter. Women were followed up either until they died or
were lost to follow-up or until the study closed. The median follow-up time
was 5,9 years. The authors investigated all cause death, AIDS related death,
and a 50% decrease in CD4 cell count. The analysis, conducted using adjusted
models, showed an association between anemia and an increased risk of all
cause mortality and AIDS-related mortality, independent of CD4 cell count, WHO
clinical stage, age, pregnancy, vitamin supplementation, and BMI. Anemia was
also associated with a more rapid decline to 50% of baseline CD4 counts. Iron
deficiency, defined by erythrocyte characteristics, was associated with
all-cause and AIDS-related death and a 50% decline in CD4 cell count. The
authors finally recommend that the screening, prevention and treatment of
anemia should be included in HIV care intervention, particularly to those
focusing on women.
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Obimbo EM, Mbori-Ngacha DA, Ochieng JO
et al. Predictors of early mortality in a cohort of human immunodeficiency virus
type 1-infected African children. The Pediatric Infectious Disease Journal,
2004, 23(6): 536-543.
This prospective observational study aimed to investigate the predictor of
mortality among HIV-infected African infants during the first two years of
life. Infant from a perinatal cohort were selected and followed monthly until
1 year and quarterly until two years or death. Among 62 HIV-infected infants
included, infection occured by the age of 1 month in 56 (90%) infants, and 32
(52%) died at median age of 6.2 months. All infant death were caused by
infectious diseases, pneumonia and diarrhea. Among other univariate predictors
of infant mortality maternal anemia and formula-feeding are evaluated (hazard
ratio (HR)=3,7; p=.005 and HR=4,0; p=.001). In multivariate analysis, maternal
CD4 count cells <200 (HR=2,7; p=.03) and delivery complications (HR=3,4;
p=.005) were independently associated with infant mortality. Data presented
here may be useful for an early identification and treatment of high risk
infants.
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Olsen A, Mwaniki D, Krarup H et al.
Low-dose iron supplementation does not increase HIV-1 load. Journal of Acquired
Immune Deficiency Syndrome, 2004, 36: 637-638.
Iron supplementation may increase HIV replication and the rate of
progression of HIV-infection. This mechanism could interfere with the
international objective to combat iron deficiency. The author conducted a
retrospective study on data from 1994 concerning a randomized,
placebo-controlled, double-blind iron supplementation among adults in Kenya.
The aim of the study was to assess the effect of 60 mg of elemental iron given
twice a week during 4 months on HIV-1 viral load. Anonymous HIV testing was
performed on repository samples. Of the 181 participants, 45 were found to be
HIV-positive and 32 of these had serum data available. Compared to placebo, 60
mg of elemental iron twice a week for 4 months did not increase HIV load, but
the effect of higher doses of iron cannot be excluded.
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Otieno PA, Brown ER, Mbori-Ngacha DA et al. HIV-1 disease progression
in breastfeeding and formula-feeding mothers: a prospective 2-year comparison of
T cell subsets, HIV-1 RNA levels, and mortality. Journal of Infectious Diseases,
2007, 195: 220-229.
The current policies on infant feeding option in HIV setting is based on
infant factors. As maternal health is also an important independent outcome
some authors concurrently considered the impact of the mode of infant feeding
on maternal health. Maternal health is known to improve child survival and
development. To date conflicting evidence remain on the effect of
breastfeeding on maternal health in HIV settings. This prospective study aims
to compare immunological and viral markers of HIV disease progression, as well
as the risk of mortality between breastfeeding and formula feeding
HIV-positive women in Nairobi, Kenya. 296 HIV-positive women were enrolled
during pregnancy. Written informed consent was obtained, and women were
counselled on safe infant-feeding options and were given at least 2 weeks to
decide on how they planned to feed their infants. All women received antenatal
care and a short course of zidovudine. Viral load and CD4 cell counts were
determined at baseline and at different time after delivery and were compared
between breastfeeding and formula feeding mothers. 98 mothers decided to
provide formula feeding to their infant and 198 decided to breastfeed. At
baseline formula-feeding women had higher education level and prevalence of
HIV related illness. Both groups were similar concerning viral load and CD4
cell counts at baseline. During follow up the rate of CD4 cell count decline
was significantly higher in the breastfeeding arm than in the formula-feeding
group (7,2 vs 4,0 cells/μL/month, p=.01). Similarly BMI decreased more rapidly
in the breastfeeding group than in the formula feeding group (p=.04), whereas
there was no differences in mortality and viral load. These results suggest a
limited adverse impact of breastfeeding in mothers receiving extended care for
HIV-infection.
Click here for Pubmed summary. See also
editorial comment in the same issue of the journal on pages 165-167.
Papathakis PC, Rollins NC, Chantry CJ et
al. Micronutrient status during lactation in HIV-infected and HIV-uninfected
South African women during the first 6 mo after delivery. American Journal of
Clinical Nutrition, 2007, 85(1): 182-192.
Up to now few information is available on protein and micronutrient status
of HIV-infected breastfeeding women. Therefore this study aimed to compare
nutrient status of South African breastfeeding women by HIV status. Serum
albumin, prealbumin, vitamin B-12, folate, retinol, alpha-tocopherol,
hemoglobin, ferritin, and zinc concentrations were compared between
HIV-infected and HIV-negative mothers at 6, 14, and 24 weeks after delivery.
The authors also planned to control for acute phase response and therefore CRP
and alpha 1-acid glycoprotein were used as markers of an inflammatory process.
Data of 92 HIV-positive and 52 HIV-negative women were obtained. Mean albumin
and prealbumin were significantly lower in HIV-infected mothers, and a higher
proportion of these mothers had low albumin concentration (<35 g/L). Nearly
the half of all mothers were deficient in vitamin B12 or folate. Significantly
more HIV-positive than HIV-negative mothers had low vitamin B12 status
(p<.05), and mean folate concentrations were lower in HIV-infected mothers
(p=.05). After control for acute phase response mean serum retinol was
statistically lower among infected mothers. After 24 weeks alpha-tocopherol
deficiency was observed in a majority of women from both groups, but no
significant difference was noted by HIV status. Anemia was more prevalent
among HIV-infected women (p=.018), while 25% of all mothers had low serum
ferritin concentrations. Zinc deficiency was more common among infected women
(p=.05). This study brings biochemical evidence that multiple micronutrient
deficiencies are common among clinic attending South African breastfeeding
women between 6 and 24 weeks after delivery. This phenomen is observed
regardless of HIV status. Micronutrients deficiencies are associated with
disease progression, reduced CD4 cell counts, and increased morbidity and
mortality in HIV-positive persons. These data suggest that a multiple
micronutrient supplement is currently indicated for HIV-positive persons, at
least until an improved and diverse dietary intake is achievable.
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Paton 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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Piwoz E et al. Nutrition and HIV/AIDS: Evidence, gaps, and priority
actions. The Support for Analysis and Research in Africa (SARA) project, 2004
This document summarizes the evidence, gaps, and priority actions related
to nutrition and HIV/AIDS. It brings a global view about nutrition and
HIV/AIDS, and provides information about energy requirement, disease
progression under micronutrient deficiencies, and about malnutrition during
HIV infection. The complex interactions between livelihoods, food security and
HIV/AIDS are also discussed. The endpoint supports that nutrition counseling,
care and support are integral to comprehensive HIV care.
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Piwoz EG, Bentley ME. Women's voices,
women's choices: The challenge of nutrition and HIV/AIDS. Journal of Nutrition,
2005, 135 (4):933-937.
This article is part of a symposium that took place in April 2004 in
Washington, DC. This introduction paper to the symposium proposes a brief
description of its content, including new data from qualitative research,
clinical trials, and behavioral interventions. The countries represented were
Malawi, South Africa, Tanzania and Zimbabwe. The article rapidly reviews
nutrition issues among infected women and their children. It focuses on women,
because of their higher sensibility to the burden of HIV infection, and
responsibilities for providing food and care for orphans and HIV-affected family
members.
Click here for Pubmed summary.
NEW! Reid C, Courtney M. A randomized
clinical trial to evaluate the effect of diet on weight loss and coping of
people living with HIV and lipodystrophy. Journal of the Association of Nurses
in AIDS Care, 2007, 16 (7b): 197-206.
Click here for Pubmed summary.
Smith Fawzi MC, Kaaya SF, Mbwambo J et
al. Multivitamin supplementation in HIV-positive pregnant women: impact on
depression and quality of life in a resource-poor setting. HIV Medicine, 2007,
8(4): 203-212.
Major depression has been shown to be highly prevalent among HIV-positive
persons, and depressive symptoms or depression have been shown to be elevated
in HIV-positive and negative pregnant women attending prenatal, prevention of
mother-to-child transmission or other healthcare services. Therefore there is
a great need to identify strategies to improve the quality of life and related
psychosocial outcomes of those persons. According to cross-sectional studies
among HIV-negative population there is some evidence that micronutrients
(especially b-complex vitamins) could demonstrate a protective effect on
depression. The main objective of this study was to examine the effect of
vitamin supplementation on health-related quality of life and on the risk of
elevated depressive symptoms comparable to major depressive disorder in
HIV-positive pregnant women in Dar es Salaam, Tanzania. 1078 HIV-infected
pregnant women were enrolled in a double-blind, placebo-controlled trial. The
participants were not under antiretroviral treatment and received daily either
vitamin A alone, multivitamins excluding vitamin A, multivitamin plus vitamin
A or placebo. The effects of vitamin supplementation was assessed every 6-12
months. Depressive symptoms and health-related quality of life were measured
through validated questionnaires. Elevated depressive symptoms was observed
among 42% of the population. Multivitamin supplementation demonstrated a
protective effect on depression (RR=0.78, p=.005) and on some characteristcs
of quality of life. Vitamin A showed no effect on these outcomes. These
results could be explored further among patients who require antiretroviral
therapy.
Click here for Pubmed summary.
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.
Click here for Pubmed summary.
van Lettow M, Harries AD, Kumwenda JJ et
al. Micronutrient malnutrition and wasting in adults with pulmonary tuberculosis
with and without HIV co-infection in Malawi. BMC Infectious Diseases, 2004, 4:
61.
This cross sectional study investigates the interaction between
tuberculosis, micronutrients malnutrition and HIV viral load. The authors
hypothesized that micronutrient malnutrition is associated with wasting and
higher plasma HIV viral load in adults with pulmonary tuberculosis. They
included 579 HIV-positive antiretroviral naive adults and 222 HIV-negative
under antiretroviral therapy adults with pulmonary tuberculosis in Malawi.
Body Mass Index (BMI), plasma micronutrients and plasma viral load were
assessed. BMI allowed wasting severity levels classification. The risk of
micronutrient deficiencies was therefore examined at different severity levels
of wasting. Plasma viral load was inversely associated to BMI, plasma retinol,
carotenoid and selenium concentration. Vitamin A, zinc and selenium deficiency
were common (61%, 85% and 87% respectively). Wasting defined as BMI<18,5 was
also frequent (59%) and independantly associated with a higher risk of low
carotenoids, and vitamin A and selenium deficiency. Severe wasting, defined as
BMI <16,0 showed the strongest associations with deficiencies in vitamins A,
selenium and plasma carotenoids. The present results suggest that
micronutrients malnutrition and wasting are more severe in adults with
pulmonary tuberculosis who have higher HIV load. Longitudinal studies are
however required to support these results.
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entire article.
Villamor A, Aboud S, Koulinska IN et al.
Zinc supplementation to HIV-1-infected pregnant women: effects on maternal
anthropometry, viral load, and early mother-to-child transmission. European
Journal of Clinical Nutrition, 2006, 60(7): 862-869.
This double blind placebo controlled randomized clinical trial aims to
investigate the effect of zinc supplementation among HIV-infected pregnant
women. The outcomes of interest are viral load, early mother-to-child
transmission of HIV (MTCT) and wasting. 400 Tanzanian HIV-infected pregnant
women were randomly assigned to receive daily doses of 25 mg zinc or placebo
from the day of the first prenatal visit until 6 weeks after delivery.
Anthropometric measures were performed monthly and HIV status of babies was
assessed at birth and 6 weeks postpartum. Viral load was controlled in a
random sample of 100 women at baseline and at the end of the research. The
supply had no effects on maternal viral load or early MTCT. Zinc supplement
was associated with an increased risk of wasting (RR=2,7, 95% CI=1.1, 6.4,
p=.03) and to a 4 mm decline in mid upper arm circumference during the second
trimester (p=.02). These findings suggest that zinc supplementation does not
provide any benefits on viral load or MTCT and the clinical relevance of its
impact on mid upper arm circumference needs to be ascertain. Therefore these
data do not support addition of zinc supplements to the standard care of
prenatal care among HIV-infected pregnant women.
Click here for Pubmed summary.
Villamor E, Saathoff E, Mugusi F et al.
Wasting and body composition of adults with pulmonary tuberculosis in relation
to HIV-1 coinfection, socioeconomic status, and severity of tuberculosis.
European Journal of Clinical Nutrition. 2006, 60(2): 163-171.
This cross sectional study aimed to investigate the impact of HIV
infection, socioeconomic status and the severity of tuberculosis on body
composition and anthropometric status of adults with pulmonary tuberculosis.
The authors included 2231 Tanzanian adult women and men attending to five
clinics in Dar es Salaam and diagnosed with tuberculosis. They compared the
distribution of some anthropometric characteristics by HIV status,
socioeconomics status and indicators of tuberculosis severity. In a subsample
of 731 participants comparable analysis were performed with body composition
variables issued from bioelectrical impedance analysis. Multivariate analysis
was carried out and HIV infection was statistically associated with lower mid
upper arm circumference and arm muscle circumference among women and men.
HIV-infected participants had significant lower body cell mass, intracellular
water and phase angle compared to HIV-free participants. Albumin was also
significantly lower among women and men infected with HIV. HIV infection was
associated with indicators of low lean body mass in adults with tuberculosis.
Independently of HIV socioeconomic factors and tuberculosis severity appeared
as important correlates of wasting.
Click here for Pubmed summary.
Villamor E, Kapiga SH, Fawzi WW. Vitamin
A serostatus and heterosexual transmission of HIV: case-control study in
Tanzania and review of the evidence. International Journal for Vitamin and
Nutrition Research. 2006, 76(2):81-85.
The role of vitamin A/beta-carotene supplementation among HIV-infected
pregnant and lactating women has been fairly studied. The potential role of
vitamin A on heterosexual HIV transmission has only raised limited interest.
In many resource limited settings where both vitamin A deficiency and HIV
infection are highly prevalent this question may be highly relevant. This
article presents a case control study (n=72) among a cohort of HIV-negative
women attending family planning clinics in Tanzania. The authors aimed to
examine whether low serum concentrations at baseline were associated with the
risk of seroconversion. No significant association was detected (OR=2.14, 95%
CI=0.54, 8.45). According to this and other works, it seems there is not
enough evidence to suggest an association between vitamin A and an eventual
higher heterosexual HIV transmission.
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Villamor E, Saathoff E, Manji K et al.
Vitamin supplements, socioeconomic status, and morbidity events as predictors of
wasting in HIV-infected women from Tanzania. American Journal of Clinical
Nutrition, 2005, 82(4): 857-865.
The effect of wasting in HIV-infected persons are diffcult to inverse, and
wasting has been described to be a strong predictor of mortality in those
persons. The exact sequence of events leading to wasting has not yet been
completely described. Vitamin supplements, a low cost means, have been
proposed to prevent disease progression. This randomized placebo controlled
trial aimed at investigating the effect of different daily oral multivitamin
regimens on wasting in HIV-infected women and to assess the effects of
sociodemographics characteristics, morbidity events, and immunologic
progression on the risk of wasting. 1078 Tanzanian HIV-infected women were
included to receive: multivitamins (B complex, C and E), vitamin A plus
beta-carotene, multivitamins that included vitamin A plus beta carotene, or
placebo. Endpoints included first episode of midupper arm circumference <22cm
or a BMI <18 and the incidence of weight loss episodes dring an average of 5
years of follow-up. Analysis was based on intention to treat. It occurs that
multivitamins alone significantly reduced the risk of a first episode of a low
mid-upper arm circumference. The age, education level and heigth were
inversely related to the incidence of wasting. Some morbidity characteristics,
such as diarrhea, nausea or vomiting, lower respiratory tract infections, oral
ulcers, thrush, severe anemia, and low CD4+ were related to a higher risk of
wasting. It seems that vitamin B and vitamins C and E reduce the risk of
wasting. The authors end with a call for further research analysing if
supplementation with doses resembling to the recommended dietary allowance
have the same benefit effects as the doses used in this study.
Click here for PubMed Summary.
Villamor E et al. Child mortality in relation to HIV infection,
nutritional status, and socio-economic background. International Journal of
Epidemiology, 2005, 34:61-68.
The objectives of this study are to examine the impact of HIV infection on
mortality and to identify nutritional and sociodemographic factors that
increase the risk of child mortality independent of HIV infection. This
prospective study in Dar es Salaam followed up children admitted to hospital
with pneumonia. After discharge, children were followed up every 2 weeks
during the first year and every 4 months thereafter. Sociodemographic
characteristics were determined at baseline, and HIV status, hemoglobin, and
malaria infection were assessed from a blood sample. The mean age at enrolment
was 18 months. HIV infection was associated with an adjusted 4-fold higher
risk of mortality. Other risk factors included child’s age < 24 months,
stunting, low mid-upper arm circumference, anemia, and lack of water supply in
the household. HIV infection seems to be a strong predictor of death among
children who have been hospitalized with pneumonia. According to this well
build study, preventable conditions including inadequate water supply, child
undernutrition, and anemia contribute significantly to infant and child
mortality independent of HIV infection.
Click here for the entire article.
In this section you will find relevant documents older than 2004:
Dreyfuss ML, Fawzi WW. Micronutrients and vertical transmission of HIV-1.
American Journal of Clinical Nutrition, 2002, 75(6):959-970.
This complete article summarizes the effects of micronutrients status and
supplementation on vertical transmission of HIV. Vertical transmission can
occur during pregnancy, at the time of delivery, or post-natally through
breastfeeding and is a major factor in the continuing spread of HIV infection.
This document explains the potential mechanisms of action for micronutrients
in the vertical transmission of HIV. Inadequate nutritional status may
increase the risk of vertical HIV transmission by influencing maternal and
child factors for transmission. The authors draft a summary of evidence of the
relation between micronutrients and HIV disease progression by comparing the
endpoint of numerous trials. The ability of prenatal and postpartum
micronutrient supplements to reduce transmission during the breastfeeding
period is still unknown.
Click here for the
entire article.
Fawzi W. Micronutrients and human immunodeficiency virus type 1 disease
progression among adults and children. Clinical Infectious Diseases, 2003,
37(S2):112-116.
Nowadays trials have shown positive effect of vitamins B, C and E
supplements on the immune status of HIV-infected persons. This article
examines, according to observational and randomized trial data, the potential
roles of micronutrients in slowing HIV-1 disease progression. Relationships
between micronutrients status and HIV disease progression among adults and
children are presented in a clear table. The authors call for larger trials to
examine the efficacy of micronutrient supply on clinical outcomes and to find
out if the benefits are sustained after the first weeks of the trial. More
data are as well needed to justify the effect of trace elements like selenium
and zinc, among HIV-infected persons.
Click here for the entire article.
Grinspoon S, Mulligan K. Weight Loss and Wasting in Patients Infected with
Human Immunodeficiency Virus. Clinical Infectious Diseases, 2003, 36(S2):69–78.
Up to now HIV infection lead to wasting, particularly loss of metabolically
active lean tissue, even in the era of highly active antiretroviral therapy.
The wasting syndrome has been associated with increased mortality, accelerated
disease progression, loss of muscle protein mass, and impairment of strength
and functional status. Many factors have been associated to the wasting
syndrome: malabsorption disorders, inadequate intake, metabolic alterations,
hypoganadism, and excessive cytokine production. Some medical, physical and
nutritional treatment seems to have a positive impact on weight and lean body
mass gain. According to the authors, this article is the first to propose
principles and guidelines for assessment and management of weight loss and
wasting in patients with HIV/AIDS.
Click here for the entire article.
Jiamto S et al. A randomized trial of the impact of multiple
micronutrient supplementation on mortality among HIV-infected individuals living
in Bangkok. AIDS, 2003, 17(17):2461-2469.
The objective of this randomized placebo-controlled trial held in Bangkok
was to evaluate the impact of commercially available micronutrients on
survival and disease progression in HIV infected people. The authors
considered this question as a high public health importance because
micronutrients are cheap and easily tolerated. After analysis the authors
found there was a lower death rate in the micronutrient arm of the study, and
it was statistically significant. On the other hand there was no impact on CD4
cell count or plasma viral load. If the clinical findings of this trial are
confirmed by other studies, it may have important public health implications
in the developing world where access to antiretroviral therapy remains poor.
Click here for the entire article.
Nerad J et al. General nutrition management in patients infected with
human immunodeficiency virus. Clinical Infectious Diseases, 2003, 36(S2):52-62.
This document places the nutritional management as an integral care of all
patients infected with HIV. The infection results in complicated nutritional
issues for patients, and there is growing evidence that nutritional
interventions influence health outcomes in HIV-infected patients. The article
suggests that the initial visit of a new HIV-positive patient should include
screening for nutritional risk and appropriate nutrition counseling. It
provides information about HIV medication and food interactions, and about
nutritional screening tools that exist. The authors define levels of
nutritional care, and discuss when patients should be referred to providers
with nutritional and HIV expertise.
Click here for the entire article.
RCQHC/ FANTA project/ LINKAGES project/ SARA Project. Nutrition and
HIV/AIDS: A Training Manual. Kampala, RCQHC:, 2003.
This training manual is intended to complement materials used by tutors in
nutrition and health institutions of higher learning to train people in the
area of nutrition and HIV/AIDS. The objective of this manual is to provide a
comprehensive source of information on nutrition and HIV/AIDS, and provide
tutors with technical content, presentations, and handout materials that can
be used for planning and facilitating courses and lectures.
Click here for
the entire article. This publication can be ordered at:
mail@rcqhc.org
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