HIV/AIDS-Associated Wasting:

A Severe Malnutrition Case Study

Elizabeth Buenger
13 November 2020
 HIV in the United States
• 1.2 million individuals New HIV Diagnosis by Race/Ethnicity, 2018

• 37,968 new diagnoses

– Male
– Gay/bisexual/MSM
– POC

Photo from: https://www.cdc.gov/hiv/statistics/overview/ataglance.html

• From transmission to seroconversion
– 3 weeks to 3 months
• Rapid replication
• Decline in CD4+ cells
• Viral load stabilizes and CD4+ cell counts
normal
• Symptoms: fever, fatigue, pharyngitis,
N/V/D, malaise, general lymphadenopathy
• Clinical latency:
– Virus active and replicating
– CD4+ cell counts decline slowly
– Asymptomatic
• Acute infection
– CD4+ cell count <500 cells/µL
– Symptoms: persistent fever, diarrhea,
unintentional weight loss/HIV-associated
wasting, recurrent infections
• CD4+ cell counts: <200 cells/µL
• AIDS-defining condition
• High risk of opportunistic infections
and HIV-associated wasting

Photo from: https://clinicalinfo.hiv.gov/en/glossary/aids-defining-condition

Medical Management of HIV
• Anti-retroviral therapy (ART)
• Prophylactic ABX, antifungals
• Regular labs: CD4+ count, viral load,
albumin, hemoglobin, iron status, lipid
profile, LFTs, renal function, blood
glucose, vitamin status
• Management of comorbidities
 Goals of Medical Nutrition Therapy
• Optimize nutritional status and immunity
• Maintain healthy weight/LBM
• Prevent nutrient deficiencies
• Reduce risk of comorbidities
• Maximize effectiveness of medical
treatments
 Estimated needs for HIV/AIDS
• Resting energy expenditure: ↑ 5-17%
• Total energy expenditure: no difference
• Energy needs based on stage of disease,
presence of comorbidities, opportunistic
infections, or inflammation and effects of
medications
Introduction to the patient
• 51-year-old male
• Recent HIV/AIDS dx
• CD4+ cell count: 78
• Viral load: 238,000 copies/mL

• Admit dx: CAP, severe sepsis, AKI

• C/o weakness, decreased appetite,
oral ulcers, dysphagia/odynophagia
 Patient Assessment
• Height: 177.8 cm (5’ 10”)
Date Weight (kg) BMI
• Weight: 32.8 kg 10/19 32.8 10.4

• UBW: 125 lb 10/2 40.8 12.9

9/17 44.5 14.1
7/16 49.1 15.5
• PMH: COPD, dyslipidemia, January 56.8 18.0
CAD, current smoker, dentures
Relevant Labs
Lab 10/16 10/18 Lab 10/22 10/26 10/28
ALB 2.7 (L) 1.7 (L) Hgb 6.2 (L) -- --
ALP 96 -- Iron 83 -- --
AST 23 -- Vitamin B12 1568 (H) -- --
ALT 7 -- Folate 4.4 (L) -- --
Bili, t 0.4 -- Triglycerides -- 560 (H) 137
BUN 75 (H) 26 Vitamin D -- -- 18 (L)
Cr 1.6 (H) 0.8
GFR 45 (L) 100
BG 173 (H) 96
 Medical tests
• Blood culture: E. coli, Streptococcus
• Toxoplasma antibody: negative
• Acid-fast smear: not performed d/t specimen
• CXR: left basilar infiltrates
• VFSS: severe oropharyngeal dysphagia
• EGD with dilation: unremarkable
 Diet order
• Speech therapy recommended pt remain NPO d/t
severe oropharyngeal dysphagia
– Continued ST to safely adv diet to NDD1 pureed
with thin liquids
 Medications
• Biktarvy
• Diflucan, Valtrex, Bactrim

• IV ABX
• Magic Mouthwash

Photo from: https://www.biktarvy.com/about-biktarvy

 Reported Intakes/Diet History
• No appetite
• Difficulty eating and drinking
• Consumption of 1 meal/day x5 months
• Addition of 1 Ensure/Boost/day prior month
Nutrition-Focused Physical Exam
Subcutaneous fat loss: Temporals Severe
Orbitals Severe
Triceps Severe
Muscle wasting: Temple Severe
Clavicle Severe
Shoulder Severe
Scapula Severe
Ribs Severe
Interosseous Severe
Quadricep Severe
Gastrocnemius Severe
 Calculating Patient’s Estimated Needs
• Energy: 1485 kcal
– 30 kcal/kg + 500 kcal
• Protein: 49-66 g
– 1.5-2.0 g/kg
• Fluids: 985-1150 mL
– 30-35 mL/kg
Nutrition Diagnosis
• Inadequate oral intake
• Increased nutrient needs (protein/energy)
• Swallowing difficulty
• Unintended weight loss
 Nutrition Diagnosis Statement
• Severe malnutrition in the context of chronic illness
related to increased metabolic needs and inadequate oral
intake as evidenced by dx HIV/AIDS and COPD, reported
intakes providing <25% estimated needs x5 months,
recent unintended weight loss 16.3 kg (33% BW) x3
months with 53 lb weight loss/year, and severe
subcutaneous fat loss and muscle wasting bilaterally at
temporals, orbitals, clavicles, scapulas, shoulders, ribs,
interosseous, quadriceps, and gastrocnemius with hair
brittle and thinned.
 Interventions
• Recommend initiation of TPN to provide 100% of estimated
protein and energy needs
– If pt requiring prolonged TPN (>2 weeks), rec transition
to enteral feeding, if GI is functioning properly
– Monitor ST recs and VFSS results for need for long-term
tube feeding vs recs for diet adv
• When pt appropriate for po, rec Ensure Enlive TID w/ meals and
BID as AM/PM snack to promote adequate intakes
• Rec supplementation with multivitamin, vitamin D, folate
 Monitoring and Evaluation
• TPN initiation and advancement to goal of meeting
100% estimated needs
• ST rec for safe diet advancement or need for long
term tube feeding
• Weight trends; ideal weight gain 2 lb/week
• Labs including LFTs, renal fx, BG/glycemic control,
TGs, nutrient status; goal nutrient sufficiency
Questions?
 References
• Academy of Nutrition and Dietetics. Evidence Analysis Library: HIV/AIDS Guideline 2010.
http://www.andeal.org
• Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Updated);
vol.31. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published May 2020.
• Luckheeram, R.V., Zhou, R., Verma, A.D., & Xia, B. (2012). CD4+ T cells: Differentiation and
functions. Clin Dev Immunol, 2012: 925135.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312336/pdf/CDI2012-925135.pdf
• Mahan, L.K. & Raymond, J.L. (2017). Krause’s food & the nutrition care process (14th ed.)
Elsevier.
• Nutrient requirements for people living with HIV/AIDS : report of a technical consultation,
World Health Organization, Geneva, 13-15 May 2003.
https://www.who.int/nutrition/publications/hivaids/9241591196/en/