The human immunodeficiency virus (HIV) is an RNA retrovirus that causes a progressive failure

of the immune system, as HIV hijacks CD4+ T cells’ replication machinery in order to create more virus,
ultimately causing the cells to burst 1,2. CD4+ cells are crucial to an effective immune response in the case
of infection1,2. In 2018, approximately 1.2 million Americans were HIV positive, with 37,968 new
diagnoses3. HIV predominately affects gay or bisexual men, or heterosexual men who report male sex
partners, and disproportionally affects people of color 3. 42% of new diagnoses were Black/African
American individuals, though they make up only 13% of the US population, and 27% identified as
Hispanic/Latino though they make up only 18% of the US population 3.

HIV infection progresses though three stages. The first, acute HIV infection, is the period
between transmission of HIV to the host until seroconversion, or the production of detectable
antibodies, occurs3. The individual can be diagnosed as HIV positive by HIV rapid test, ELISA, Western
blot, or PCR at this time, generally 3 weeks to 3 months after exposure 3. HIV is transmitted primarily
through sexual contact by contact with blood, semen, preseminal fluid, vaginal fluid, breast milk, or
cerebrospinal fluid, or by intravenous drug use 3. During this period, the virus replicates rapidly and
causes a significant decline in CD4+ cell counts3. Eventually the immune response reaches a viral set
point, where the viral load stabilizes and CD4 + cell counts return closer to baseline 3.

The second stage, chronic HIV infection, begins with clinical latency, which may last ten years or
more . During this stage, the virus is active and replicating, and CD4 + cell counts slowly decline3. In 3-5%
3

of individuals, long-term non-progression occurs, where CD4 + cell counts remain normal and viral loads
are undetectable3. When CD4+ cell counts are less than 500 cells/μL, the individual becomes susceptible
to signs and symptoms of infection, including persistent fevers, chronic diarrhea, unexplained weight
loss and wasting, and recurrent opportunistic infections 3.

An individual is in the final stage of infection, acquired immunodeficiency syndrome (AIDS),

when CD4+ cell counts are less than 200 cells/μL or they are diagnosed with an AIDS-defining condition
regardless of CD4+ cell counts3. AIDS-defining conditions include candidiasis of the esophagus, bronchi,
trachea, and lungs (but not mouth), invasive cervical cancer, CMV infection, HSV related chronic ulcers,
bronchitis or esophagitis, HIV-related encephalopathy, Kaposi sarcoma, Mycobacterium avium complex
or Mycobacterium tuberculosis, Pneumocystis pneumonia, Toxoplasmosis, and wasting syndrome.
Patients are symptomatic and are at high risk of opportunistic infections 3.

The medical management of HIV is multipronged. Patients receive anti-retroviral therapy, which
is combination therapy due to the high risk of drug resistance to reduce the viral load and improve the
immune system3. Patients also often take prophylactic antibiotics and antifungals to prevent
opportunistic infections3. Labs are checked regularly to assess disease progression (viral load, CD4 + cell
count), renal and hepatic function (LFTs, BUN, creatinine, GFR), and identify comorbidities (blood
glucose, HbA1c, triglycerides) or nutrient deficiencies (iron, folate, vitamin B12, vitamin D) as they arise 3.
Metabolic syndrome, dyslipidemia, and insulin resistance are common in patients with HIV and need to
be managed as part of the treatment of HIV 3.
 Medical nutrition therapy (MNT) is an integral part of HIV management. The goals of MNT are
to optimize the patient’s nutritional status and immunity, promote general wellbeing, maintain a
healthy body weight and lean body mass, prevent nutrient deficiencies, reduce the risk of comorbidities
or reduce the severity of symptoms, and maximize the effectiveness of medical and pharmaceutical
treatments, such as anti-retroviral therapy 1. However, a patient may need to first prioritize psychosocial
issues such as depression or managing the feelings regarding the perceived stigma associated with their
diagnosis, managing the timing of meals with respect to medication administration, balancing the cost of
medical treatment with dietary recommendations or other food insecurity such as finding access to safe,
affordable and nutritious food1.

The Academy of Nutrition and Dietetics’ Evidence Analysis Library indicates the resting energy
expenditure of individuals with HIV may be increased by 5-17%; however, the total energy expenditure
in these individuals may instead by similar to individuals without HIV 4. Therefore, estimated needs
should be based on the stage of disease, presence of comorbidities, opportunistic infections, or
inflammation, and any effects of medications in order to maintain or reach a healthy body weight 4. The
World Health Organization has a different recommendation for management of HIV. They, instead,
recommend an increase of energy intake by 20-30% during periods of symptomatic disease in order to
maintain a healthy body weight5. That level of intake may not be possible during periods of illness, so
they recommend increasing intakes safely up to 30% above normal in order to support weight
maintenance or weight recovery5. Data are insufficient at present to support increased protein needs
based on HIV status alone5.

The patient of interest is a 51-year-old gay, white man who was diagnosed as HIV positive 2
weeks prior to admission. His CD4+ cell count was 78, indicating that the patient has AIDS. His viral
count was high at 238,000 cells/mL, which is unsurprising given his very recent diagnosis and initiation
of anti-retroviral therapy. The patient was admitted with diagnoses of community acquired pneumonia,
severe sepsis, and acute kidney injury. The patient complained of weakness, decreased appetite and
poor intakes prior to admission due to oral ulcers, candidiasis, dysphagia and odynophagia. The patient
was 177.8 cm tall and, at the time of assessment, weighed 32.8 kg with a BMI of 10.4. Per patient report,
his usual body weight is 125 lb, which he has not weighed in 10 months, and his BMI was 18.0. The
patient’s weight history indicates consistent weight loss over the prior three months for a total of 33%
body weight with 24 kg weight loss over the past year from the patient’s reported usual body weight.
The patient had a limited prior medical history with only a history of COPD, dyslipidemia, and coronary
artery disease; the patient is a current smoker and has dentures that he has not been wearing due to
candidiasis and chronic oral ulcers.

Upon admission, several tests were performed to assess the patient’s status. Routine labs were
performed to measure liver and kidney function, glycemic control and lipid status, as well as nutrient
sufficiency. Liver function is checked as elevated LFTs are common in patients receiving anti-retroviral
therapy; the patient’s albumin was low (1.7) otherwise LFTs were within normal limits. Renal labs are
checked as anti-retroviral therapy can cause kidney damage in patients with declining kidney function;
the patient’s renal labs indicated AKI likely secondary to dehydration as the patient’s kidney function
improved with the administration of IV fluids. The patient’s blood glucose was elevated on admission,
but quickly normalized. The patient did not have a recent hemoglobin A1c value, which is typically
checked due to the prevalence of metabolic syndrome and insulin resistance in patients with HIV. Due
to the high risk of nutrient deficiency in patients with HIV, iron status and vitamin D status were
checked. The patient had low hemoglobin, normal serum iron, elevated vitamin B12, low folate and low
vitamin D levels, indicating folate and vitamin D deficiency.

The patient’s blood culture grew E. coli and Streptococcus, which is consistent with the patient’s
diagnosis of sepsis. A Toxoplasma antibody test was performed to identify the presence of latent or
active toxoplasmosis, which is the number one central nervous system infection in HIV positive
individuals; the test was negative. An acid-fast smear to test for tuberculosis infection was originally
going to be performed; however, the patient’s sample was not appropriate for testing and a second
sample was not acquired. A chest x-ray revealed left basilar infiltrates, consistent with pneumonia.

When the patient failed the bedside swallowing exam, speech therapy recommended a video
swallow study, which revealed severe oropharyngeal dysphagia. In order to attempt to determine the
source of the patient’s dysphagia, which was initially suspected to be cytomegalovirus esophagitis or
Candida esophagitis, an EGD with dilation was performed. The EGD was negative for both CMV
esophagitis and Candida esophagitis and was otherwise unremarkable and the presumed cause of the
patient’s dysphagia is overall debility and weakness secondary to HIV wasting. Speech therapy
recommended the patient remain NPO due to the severity of his oropharyngeal dysphagia with
continued speech therapy with a goal to safely advance diet to the National Dysphagia Diet Level 1
pureed with thin liquids.

Prior to admission the patient was prescribed Biktarvy to reduce HIV viral burden and improve
his immune system. Biktarvy is a combination retroviral therapy containing an integrase strand transfer
inhibitor and two nucleoside reverse transcriptase inhibitors. He was also prescribed Diflucan, Valtrex,
and Bactrim which are an antifungal, antiviral and antibiotic in order to treat his oral ulcers and
candidiasis. Upon admission, intravenous antibiotics azithromycin, meropenem, and vancomycin were
initiated to treat his sepsis and pneumonia. Once the causative bacteria were identified, the antibiotics
were switched to Rocephin and Bactrim. The patient was also started on Magic Mouthwash which
contains an antifungal, antibiotic, steroid, and antihistamine, to treat his candidiasis and oral pain.

A consult was received for poor po intake per the patient’s admission screen, which indicated
decreased appetite and recent unintended weight loss. The patient reported prolonged poor appetite
and intakes with difficulty eating or drinking anything due to the presence of oral ulcers and painful
swallowing. For the past five months, the patient has consumed only one meal per day. In the prior
month, the patient has also consumed one Ensure or Boost supplement per day, indicating intakes
meeting less than 25% of estimated needs for the past five months.

Given the patient’s weight and diet histories, a nutrition-focused physical exam was performed.
The patient’s hair was brittle and thinned and the patient had severe subcutaneous fat loss at the
temporals, orbitals, and triceps, and severe muscle wasting at the temples, clavicles, shoulders, scapula,
ribs, intraosseous, quadriceps, and gastrocnemius, clearly indicating severe malnutrition. The patient’s
estimated needs can be calculated, based on the patient’s recent severe unintended weight loss and
severe subcutaneous fat loss and muscle wasting. Using the patient’s admission body weight of 34.7 kg,
the patient needs 1485 kcal/day (30 kcal/kg + 500 kcal), 49-66 g protein/day (1.5-2.0 g/kg) and 985-1150
mL fluids/day (30-35 mL/kg) in order to promote appropriate weight/lean body mass regain.

Considering the complexity of the patient’s condition and current status, there are several
nutrition diagnoses that would apply, including:

 Inadequate oral intake: due to the patient’s decreased appetite and intakes meeting
<25% of estimated needs prior to admission, and severe subcutaneous fat loss and
muscle wasting
 Increased nutrient needs (protein/energy): due to patient’s infections and diagnosis of
sepsis, as well as HIV-associated wasting
 Swallowing difficulty: due to the patient’s severe oropharyngeal dysphagia,
odynophagia, and oral ulcers
 Unintended weight loss: due to recent weight loss of 33% body weight over 3 months
with total weight loss of 53 pounds over one year

However, there is one diagnosis that combines all of these and is most appropriate for the
circumstances: 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.

To immediately address the patient’s severe malnutrition; I would recommend the initiation of
TPN to eventually provide 100% of estimated protein and energy needs as the patient is not safe for po
intake. If the patient requires prolonged TPN, I would recommend the transition from TPN to enteral
nutrition, if the gastrointestinal tract is functioning properly. If the patient is unable to safely take po
food and fluids at that time, I would recommend long term tube feeding placement. When speech
therapy determines the patient is appropriate for po intake, I will schedule Ensure Enlive TID with meals
and BID as an AM and PM snack while intakes remain poor. In order to treat current nutrient
deficiencies and to prevent additional deficiencies which are common with HIV/AIDS, I would
recommend supplementation with a multivitamin and folate and vitamin D specifically.

For this patient, I would monitor for the initiation of TPN and advancement to goal of meeting
100% of the patient’s estimated protein and energy needs. I would also monitor for speech therapy
recommendations for the safe advancement of the patient’s diet or the need to recommend long term
tube feeding placement. I will continue to monitor weight for trends. Ideally, the patient would gain 2
pounds per week to reach ideal body weight; however, realistically, the patient’s initial weight gain will
be slower due to his organs’ need for nutritional support in order to begin normalized function prior to
weight restoration, given his extreme malnutrition. I would also continue to monitor his labs for changes
and trends, including hepatic and renal function for any negative side effects of anti-retroviral therapy,
blood glucose, glycemic control and triglycerides due to the high risk of developing comorbidities, and
nutrient status with an overall goal of nutrient sufficiency.

In conclusion, medical nutrition therapy is an essential part of HIV/AIDS management. The

treatment plan depends on the stage of infection, presence of comorbidities, and loss of lean body
mass. In patients with severe HIV-associated wasting, the goal should be the reduction of severity of
symptoms, weight restoration, and nutritional sufficiency.

References:

1. Mahan, L.K. & Raymond, J.L. (2017). Krause’s food & the nutrition care process (14th ed.)
Elsevier.
2. 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
3. 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.
4. Academy of Nutrition and Dietetics. Evidence Analysis Library: HIV/AIDS Guideline 2010.
http://www.andeal.org
5. 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/