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The human immunodeficiency virus (HIV) is a retrovirus that infects

cells of the immune system, destroying or impairing their function.

As the infection progresses, the immune system becomes weaker,

and the person becomes more susceptible to infections.

The most advanced stage of HIV infection is acquired

immunodeficiency syndrome (AIDS).

It can take 10-15 years for an HIV-infected person to develop AIDS;

antiretroviral drugs can slow down the process even further.

Etisa AM, PS Ilmu Gizi

HIV/AIDS

In 2009, 33.3 million people were living

with HIV in the world.


3.5 million people were living with
HIV/AIDS in the South-East Asia Region in
2009
Women account for 37% of the total
number.
India, Indonesia, Myanmar, Nepal and
Thailand account for the majority of HIV
infections
In Indonesia, the HIV epidemic is still on
the rise
Etisa AM, PS Ilmu Gizi

HIV/AIDS

Epidemiology : Indonesia
The majority of HIV infections are

transmitted sexually;
Injecting drug use is the second
most common mode of HIV
transmission

Etisa AM, PS Ilmu Gizi

HIV/AIDS

Hesti MR, PS Ilmu Gizi

HIV/AIDS

HIV/AIDS

Etisa AM, PS Ilmu Gizi

HIV/AIDS

Etisa AM, PS Ilmu Gizi

HIV/AIDS

Window period = time between infection,


Ab detection: An infected person can infect others
within 2 weeks of initial HIV exposure, at a time well
before anti-HIV Abs can be detected.
Average time from initial infection to AIDS is
about 10 years, though this rate of
development is lengthening with new
treatments available.

HIV is transmitted through


unprotected sexual intercourse (both

heterosexual and homosexual; anal or


vaginal),
transfusion of contaminated blood,
sharing of contaminated needles,
Transplantation of infected tissues or organs.
between a mother - her infant during
pregnancy, childbirth & breastfeeding
Mother to fetus, perinatal transmission
variable, dependent on viral load and
mothers CD 4 count.
Etisa AM, PS Ilmu Gizi

HIV/AIDS

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Transmission

Etisa AM, PS Ilmu Gizi

What is the link


between HIV and AIDS
and Nutrition?

Link between HIV and AIDS and


Nutrition

Early detection of HIV provides an opportunity to

build up good nutritional status and healthy


eating habits

Good nutrition is a form of immune protection,

especially important in the presence of HIV

The metabolism of a person living with HIV is altered


If nutritional needs are not met, the body is more

susceptible to infections and may take longer to


recover from minor illnesses

This leads to a cycle of more weight loss, more

vulnerability, and worsening illness

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One of the most common signs of HIV

progression is weight loss


Unexplained weight loss (>10% of body

weight) is one of the signs used to indicate


that a patient is moving from the
asymptomatic phase towards AIDS
There are 2 patterns of weight loss:
First pattern is a slow gradual decline in
weight over time with HIV infection
Second pattern is a rapid and drastic weight
loss often associated with a serious infection
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HIV and Nutrition:


Effects on the Immune System

HIV progressively destroys the immune


system, leading to opportunistic
infections (OI) and debilitation.

Pre-existing undernutrition makes it


difficult for PLHIV to stay healthy and
productive.

Both HIV and undernutrition limit the


ability to fight infection and stay healthy.
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Essential Nutrients
Poor nutrition
Weight loss, muscle
wasting, macro or
micronutrient
deficiency

Increased
nutrition
needs
because of
malabsorption,
decreased food
intake, infections,
and viral replication

HIV

Impaired
immune
system
Poor ability to
fight HIV and
other infections

Increased
vulnerability to
infection and
increased frequency
and duration of
opportunistic infections

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Essential Good
Nutrients
nutrition
Weight regained or
maintained, no
macro or
micronutrient
deficiency

Nutritional
needs met
Additional energy
needs met,
adequate diet,
dietary
management of
symptoms

Nutrition
interventio
ns

Stronger
immune
system
Improved ability
to fight HIV and
other infections

Reduced
vulnerability to
infection and
reduced frequency and
duration of
opportunistic infections

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Psychosocial Factors for


Malnutrition
Food scarcity
Financial constraints
Family disruption
Loss of financial breadwinner
Loss of primary caregiver due to

illness or death
Mental health factors: depression

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Effect of HIV/AIDS on
Nutrition:
Reduced Absorption

HIV is associated with reduced

absorption of food/nutrients
Caused by HIV infection, OIs and ART
Mediated by diarrhea and damage to

intestinal cells
Results in poor absorption of fats
Reduces absorption of fat-soluble
vitamins, such as vitamins A and E

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Effects of HIV on Nutrition:


Wasting
Severe malnutrition in HIV-infected persons is

recognized as wasting, defined as:


Body weight loss of > 10%
With associated fatigue, fever, and diarrhea

unexplained by another cause

Etiology is multifactorial
Any weight loss of > 5% is associated with

accelerated disease progression, impaired


functional status, and increased mortality
Wasting is a WHO Stage 4 diagnosis
and is a criterion for ARV initiation
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AIDS-Associated Wasting
Syndrome

Increases morbidity and mortality

Associated with

Reduced energy intake

Metabolic changes

Infections and gastrointestinal disorders


including diarrhea and malabsorption

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Malnutrition and
HIV/AIDS
Low BMI is associated with disease

progression and death


Nutrient deficiencies (vitamins A,
B12, E, selenium, and zinc) are
associated with worse outcomes
HIV transmission
Disease progression
Mortality

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Malnutrition and
HIV/AIDS
Affect the body in similar ways
Affect the ability of the immune system

to fight infection and keep the body


healthy through:
Disrupts CD4 number / function
Disrupts CD8 number / function
Alters delayed type cutaneous

hypersensitivity
Alters CD4 / CD8 ratio
Impairs antibody response
Impairs bacteria killing

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Major Target Cells for HIV


Infection
CD4+ T-Lymphocytes
CD4+ monocytes and macrophages (inclu.

microglia)
CD4+ Dendritic cells (inclu. Langerhans cells)

Expressed on T-helper lymphocytes


signaling other cells in immune system
healthy: 800~1200 CD4+ T cells/mm3
AIDS: <

200 CD4+ T cells/mm3

Nutrition in the Different Phases


of HIV

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Nutrition in the Different Phases of HI

Asymptomatic phase: Energy and


nutrient needs increase because of virus
replication

Symptomatic phase: Energy and nutrient


needs increase even more because of
virus replication and the effects of HIVrelated symptoms

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Stages of HIV Disease and


Nutrition
Specific nutrition recommendations vary

according to the underlying nutritional


status and extent (stage) of HIV disease
progression
The disease progression may be
categorized into three stages:
Early: no symptoms, stable weight
Middle: significant weight loss
Late: symptomatic, full-blown AIDS
disease
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Early Stage
No symptoms, stable weight
Increased nutritional requirements during HIV-

infection

Energy increase: 10 - 15%


Protein increase: ~ 50%
Vitamins and minerals used by the immune system are

also increased

Main objective: remain as healthy as possible


Build stores of essential nutrients

Identify locally available and acceptable foods


Maintain weight and lean body mass, preserve muscle
mass, and increase energy
Adequate diet
Maintain physical activity
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Early Stage
Safe food and water handling practices
Wash hands before preparing and eating food,

after using the toilet or changing nappies or


diapers
Wash all food preparation surfaces, utensils and
dishes
Wash all fruit and vegetables before eating,
cooking or serving
Avoid letting raw food come in contact with
cooked food
Cook food thoroughly (especially chicken and
meats)
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Early Stage
Safe food and water handling

practices continued
Serve food immediately after preparation
Keep food covered and away from

insects, rodents and other animals


Do not store cooked food
Use safe water for drinking, cooking, and
cleaning dishes and utensils
Never use bottles with teats for feeding
infants; use a cup instead
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Middle Stage
Significant, unintentional or undesirable

weight loss as a result of opportunistic


infections
Main objective: minimize consequences

Increase nutrient intake for recovery/weight gain


Maintain intake during periods of acute illness and

depressed appetite
Increase nutrition intake gradually to promote
weight and muscle mass gain, and nutritional
recovery
Make every bite count
Daily vitamin-mineral supplements
Continue physical activity as able
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Middle Stage
Manage and treat the symptoms that

affect food intake:


Seek medical attention immediately if
Diarrhea is persistent and/or

accompanied by fever
Fever lasts for more than 3 days
Mouth and throat sores are present

Avoid unhealthy behaviors


Alcohol, smoking and drug use
Unsafe sexual practices
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Late Stage
Symptomatic, full-blown AIDS disease
Main objective: provide comfort or

palliative care
Treat all infections that affect intake
Modify diet according to symptoms
Maintain intake during periods of acute

illness and depressed appetite


Encourage eating and physical activity as
able
Provide psychological and emotional support
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Goals of Nutrition Care and


Support
Improve eating habits and diet to:
Maintain weight, prevent weight loss
Preserve muscle mass
Build stores of essential nutrients

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Goals of Nutrition Care and


Support
Prevent food-borne illnesses by

promoting
Hygiene
Food and water safety

Manage symptoms affecting food

intake by
Treating opportunistic infections
Treating pain

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Loss of Appetite
Eat small, frequent meals throughout

the day (5-6 meals/d)


Make every bite count
Drink plenty of liquids
Take walks before meals the fresh
air helps to stimulate appetite
Have family or friends assist with
food preparation
Mouth care is advisable
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Sore Mouth and Throat


Avoid citrus fruits, and acidic or spicy

foods
Eat foods at room temperature or
cold
Eat soft and moist foods
Avoid caffeine and alcohol
Frequent mouth care

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Nausea and vomiting


Eat small, frequent meals and snacks to avoid

an empty stomach
Eat dry bread or toast, and other plain dry
foods, in the morning preferably before getting
out of bed
Avoid foods with strong or unpleasant odors
Avoid fried foods
Avoid alcohol and coffee
Drink plenty of liquids
Avoid lying down immediately (at least 1 to 2
hours) after eating
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Diarrhea
Eat foods that travel slowly through the

digestive tract and decrease stimulation of


the bowel
Bananas, mashed fruits, soft white rice, porridge

Eat smaller meals, more often


Eliminate milk and milk products to see if

symptoms improve
Avoid intake of fried and high fat foods
Dont eat foods with insoluble fiber
(roughage)
For example: Take the skin off fruits and

vegetables

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Diarrhea
Drink plenty of fluids (8-10 cups/day) to

prevent dehydration
Avoid sweet drinks, drink diluted juice
instead
Avoid very hot or very cold foods
If diarrhea is severe
Give oral rehydration solution
Food may be withheld for 24 hrs or restricted

to only clear fluids (soups or tea) or soft foods


(mashed fruit, potatoes, white rice, porridge)
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Fever
Drink plenty of fluids
Eat small frequent meals, including

snacks between meals


As tolerated at regular intervals

Mouth care is advisable


Add snacks between meals

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Altered Taste
Use flavor enhancers such as salt

and a variety of herbs and spices


Try different textures of food
Chew food well and move it around
the mouth
This stimulates taste receptors

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Poor Fat Absorption


Eliminate oils, butter, margarine, ghee,

and foods that contain or were prepared


with them
Eat lean meats
Trim all visible fat and remove skin from

chicken

Avoid deep fried, greasy, and high fat

foods
Eat fruits and vegetables and other lowfat foods.
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Fatigue, Lethargy
If possible, have someone pre-cook

foods

This will help the patient conserve energy

Eat fresh fruits that dont require

preparation in-between meals


Eat smaller, more frequent meals and
snacks throughout the day
Exercise as able
This will increase energy

Try to eat at the same time each day.


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Some Recommended Foods


Food Group

Food

Protein
(body-building
foods)

All animal products, fish, dairy


products, legumes (beans, lentils),
groundnuts and cooked eggs

Carbohydrate
(energy-giving
foods)

Breads, cereals (maize, millet,


wheat, sorghum), rice, noodles,
potatoes, cassava, yam, sweet
potatoes, plantain

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Some Recommended Foods


Food Group

Food

Fruits/Vegetables
(source of many vitamins
and minerals)

Any fruits or vegetables

Fats/Oils
(source of
fat soluble vitamins A, E,
D &k and energy)

Palm oil, vegetable oils,


margarine, butter, ghee

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Foods to Avoid
Raw eggs
Undercooked chicken and meats
No raw, rare, or medium rare meats

Water that is not boiled or juices that are

made from water that is not boiled.


Alcohol and coffee
Junk foods such as chips, biscuits, and
sweets with little nutritional value
Foods that aggravate symptoms related to
diarrhea, nausea/vomiting, bloating, loss of
appetite, and mouth sores
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Nutrition and Medication


Medications used to treat HIV opportunistic

infections may cause drug-nutrient


interactions or side effects:
Vitamin B6 supplementation should be

administered with isoniazid therapy for


tuberculosis to avoid Vitamin B6 deficiency
Iron- and zinc-containing supplements should

not be taken with ciprofloxacin


Sulfadoxine and Pyrimethamine (Fansidar ) is

not recommended unless folinic acid


supplement is given
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Nutrition and Medication


(2)
Antiretroviral drugs may have:
Dietary requirements (e.g., with or

without food)
Side effects with nutritional
consequences such as diarrhea or
nausea/vomiting
An effect on red blood cell production
causing anemia (e.g., Zidovudine - AZT)

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Nutrient requirements for HIV+ in


relation to Normal Dietary
Requirements

*Adapted from WHO, 2003: Nutrient requirements for People Living with HIV/AIDS, Report of technical
consultation. Geneva, WHO. Refer to this document for details and discussions on nutrient
requirements

Nutrition during pregnancy and early infancy for those


affected by HIV (WHO, 2010)
The best way to approach nutritional care and prevent mother-to-child

transmission of HIV:
Appropriate health care during pregnancy (with ART)
Breastfeeding exclusively in the first 6 months and continue up to at least a
year
Replacement feeding if acceptable, feasible, affordable, sustainable and safe
(AFASS)
Asymptomatic HIV positive lactating women require the same increase in

rations and micronutrients as HIV-ve lactating women, plus an additional 10%


for maintaining health in the context of HIV

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The Multidisciplinary
Team
A multidisciplinary team is crucial to

address the many complex and varied


factors in the care of HIV-infected
patients and their families
Each member of the team can help
address these issues in their own way:
Nurses and nutritionists
Counselors
Community workers and agencies
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Lymphadenopathy

Etisa AM, PS Ilmu Gizi

HIV/AIDS

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Skin and oral disease

Hesti MR, PS Ilmu Gizi

HIV/AIDS

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Herpes zoster (shingles)

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HIV/AIDS

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Oral Candidiasis

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HIV/AIDS

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Hesti MR, PS Ilmu Gizi

HIV/AIDS

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Infeksi
Cytomegalo
virus
(retina)

Etisa AM, PS Ilmu Gizi

HIV/AIDS

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Herpes Simplex Virus Infx.

Hesti MR, PS Ilmu Gizi

HIV/AIDS

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PML

Etisa AM, PS Ilmu Gizi

HIV/AIDS

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Non-tuberculous
mycobacterial infx.

Hesti MR, PS Ilmu Gizi

HIV/AIDS

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Limfoma maligna nonHodgkin sel B

Hesti MR, PS Ilmu Gizi

HIV/AIDS

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Kaposis sarcoma (KS)


Kaposis sarcoma

(shown) is a rare
cancer of the blood
vessels that is
associated with HIV. It
manifests as bluishred oval-shaped
patches that may
eventually become
thickened. Lesions
may appear singly or
in clusters.

Disseminated Mycosis

Hesti MR, PS Ilmu Gizi

HIV/AIDS

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Conclusions
HIV affects nutrition by:

Reducing food consumption


Impairing nutrient absorption
Increasing energy needs
Causing HIV-associated wasting
Changing metabolism
Changing body composition

Poor nutrition affects HIV by:


Decreasing immunity
Slowing the healing process
Possibly hastening disease progression

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