This document provides definitions and information about HIV/AIDS including: - Definitions of HIV and AIDS - Global and regional statistics on HIV/AIDS prevalence and deaths - Modes of HIV transmission and risk factors - Stages of HIV infection from acute to symptomatic disease - Diagnosis and treatment of HIV/AIDS - Nutritional complications and the role of dietitians in HIV/AIDS care

1. Noraishah Mohamed Nor
Dept Nutrition Sc
IIUM

2. Definitions
 HIV
 Human Immunodeficiency Virus – a retrovirus
that targets the CD4 T helper immune cells
 AIDS
 Acquired Immunodeficiency Syndrome – the
final stage of HIV infection
 The result of infection with HIV is a inability of
the body to defend itself against other invaders
leading to opportunistic infections

3. Introduction
Global Sub-Saharan Africa
People Living 40.3 million 25.8 million
With HIV/ AIDS *57% women
(2005)
New HIV Infections 4.9 million 3.2 million
(2005) (70%)
(14,000 people
infected everyday)
AIDS Related Deaths 3.1 million 2.4 million
(2005)

4. Statistic in M’sia
HIV INFECTION AIDS CASES AIDS DEATH
YEAR
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

5. HIV/AIDS Classification

6. 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

7. ○ Exposure to blood and blood
products
 IV drug users
 Improperly screened blood and
blood products
○ Congenital exposure
 Exposure in pregnancy, labour and
breast feeding

10. 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

11. 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

12. 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

13.  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

14. 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

15. Progression to AIDS
 Typical progressors: 8-10 years asymptomatic
HIV before developing AIDS
 Fall in viremia following acute infection
 Rapid progressors
 Develop AIDS in 2-3 years following initial infection
 High 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 CD4
 Low viral burden

16. 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

17. Clinical staging based on
Natural history
 WHO staging into IV stages:
 Stage I: Asymptomatic and has normal activity
 Stage II: Symptomatic with weight loss, minor
skin problems, Herpes zooster
 Stage 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

18. 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

19. 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

20. HIV/AIDS Related
Clinical Complications
 Neuropathy
 Antiretroviral (ARV) therapies
 Dementia
 HIV infection, other infections, nutrient
deficiencies
 Pulmonary disorders
 HIV infection – low CD4 count
 Cardiac Manifestations
 Inflammation process, infections, ARV
medication

21.  Hepatic Disorders
 Opportunistic infection, anti-HIV treatment toxicity
 Anemias
 Chronic HIV, hormonal alterations, infections,
ARV medications
 Renal Failure
 ARV medications, infection
○ HIV-associated nephropathy, tubular necrosis,
nephrolithiasis (kidney stones)

22. 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

23. Nutrition Complications
 Malnutrition
 Malabsorption
 Hypermetabolism
 Diminished 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

24.  Malnutrition leads to:
 Malabsorption
 Complications with treatment regimens
 Decreased immune function
 Organ dysfunction
 Micronutrient deficiencies
 Weight 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

25.  Malabsorption:
 Most common – fat malabsorption
 Associated with:
○ Starvation-style malnutrition
○ Villous atrophy
○ Intestinal cell maturation defects
○ Increased gut permeability
○ Autonomic neuropathy
○ Gastrointestinal pathogens

26. Nutrition - Treatment Interaction
 Efficacy of treatment dependent on
nutritional status maintenance and vice
versa
 Low 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

27. Altered immune function
 Leads to:
 Hypermetabolism
 Opportunistic infections
○ Candidiasis
○ Cytomegalovirus
○ Hepatitis C
○ Herpes Simplex
○ Mycobacterium Avium Complex (MAC)
○ P. Jeroveci (PCP)
○ Many more

28. Organ Dysfunction
 Liver
 Lungs
 Pancreas
 Heart
 Small intestine

29. Micronutrient Deficiencies
 Caused by decreased absorption and
metabolism of nutrients and accelerated
turnover
 Most common:  Others documented:
○ Vitamin A  Vitamin B6
○ Vitamin E  Vitamin D
○ Vitamin B12  Folate
○ Selenium  Carotenoids
○ Zinc  Riboflavin
 Copper

30. 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 1987
 Recommended revisions:
○ Time frames for weight loss
○ Inclusion of body composition alterations
○ Guidelines for determining competing diagnoses

31.  Caused by:
 Reduced food intake
 Malabsorption
 Abnormal nutrient utilization and metabolism
 Oxidative stress
 Hormonal abnormalities
 HAART treatment
 Psychosocial difficulties

32.  More important than weight loss is body
composition alterations
 Decreased 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.

34. HAART in AIDS Wasting
 Body composition changes despite weight
maintenance
 Lean tissue wasting
 Lipodystrophy syndrome –
abnormal fat distribution
○ Fat accumulates:
 Abdomen
 Dorsocervical – “buffalo lumps”
 Breast areas
○ Subcutaneous fat loss:
 Limbs
 Face
 Upper trunk

35. Nutrition Intervention
 Goals:
 Preserve body cell mass
 Provide adequate amounts of all nutrients for
proper function
 Minimize the symptoms of intestinal
malabsorption
 Strategy  Symptom Management

36. Nutrition Assessment
 Should take place at diagnosis of
HIV
 Patient-Generated Subjective
Global Assessment (PG-SGA)
 Dietary Evaluation
 Physical Assessment
 Biochemical Assessment
 Medical History

37. Measuring Body
Composition
 Anthroprometrics
 Tricep skinfold
 Midarm 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

38. Biochemical Assessment
 Selected biochemical measures for HIV
 Immunologic
○ CD4 count
○ Viral Load
 Hematologic
○ Hemoglobin  Transferrin
○ Hematocrit  Albumin
○ Mean Corpuscular Volume  Prealbumin
○ Ferritin (Transthyretin)

39.  Organ Function  Cardiovascular
 AST  Total Cholesterol
 ALT  HDL
 BUN  LDL
 Creatinine  Triglycerides
 Endocrine  C-Reactive Protein
 Glucose  Electrolytes
 Insulin  Sodium
 Glycoslated  Potassium
Hemoglobin A1C
 Testosterone

40. 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


41. 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

42. Fluids & Electrolytes
 Fluids : 30 -35 ml/kg (8 -12 glass)
 Replacement of electrolytes (sodium,
potassium, and chloride) in the presence
of diarrhea and vomiting.

43. Symptom Management
 Nausea 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

44.  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

45. 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

46.  High energy, high-protein oral
supplement
 Prospective intervention trial (N=17) Boston, MA
 Take 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 UBW
 10 gained weight, 2 maintained
 4 lost weight – possibly due to secondary
infection
 Mean weight gain = 1.1 kg

47.  Glutamine (GLN) -Antioxidant
Supplementation
 Increase 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

48. 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

49. Questions?
? ??
? ??
?

50. “Do What you Can
with what you Have
Where you Are !”

51. Assignment….
 Nutrition & Bone health
 Nutrition for oral & dental health
 MNT for psychiatric disorder