12

Nutrition
and HIV/AIDS

Li Jibin, Ph.D
Department of Nutrition and Food Hygiene
School of public health and management, CQMU
Concepts of HIV and AIDS

HIV
• The human immunodeficiency virus (HIV) belongs to
retrovirus, which attacks the immune system (CD4+
helper T cells) and disables a person’s defenses
against other diseases, including infections and
certain cancers.
HIV life cycle
Concepts of HIV and AIDS

AIDS
• The symptomatic condition of HIV infection is called
acquired immunodeficiency syndrome (AIDS).
• Progression to AIDS has the potential to make the
patients vulnerable to opportunistic infections or
cancers that can cause a range of disabilities or
death.
Concepts of HIV and AIDS

PLWHA
• The acronym for “people living with HIV/AIDS”.
• Other acronyms include PLHA (people living with
HIV and AIDS) and PWA (people with AIDS).
Concepts of HIV and AIDS

ARV and HAART

• ARV is the abbreviation for “antiretroviral”. ARV
refers to medications targeted to interrupt the virus
life cycle.

• HAART is the acronym for

“highly active antiretrovirus
therapy”. HAART is a
combination of ARVs that is
able to fully suppress the
virus. HAART is used to be
called “cocktail therapy”.
Epidemiology of HIV infection

Source: UNAIDS/WHO estimates

People living with HIV by WHO region (2017)
2017
Globally
36.9 million +14%
People living with HIV
Relative to 2010
 - 18%
2017
New infections annually
Globally relative to 2010
36.9 million
People living with HIV
- 34%
Deaths annually
relative to 2010
Decline in HIV incidence and mortality over time
Risk factors for HIV infection

• HIV is transmitted from person to person

through infected body fluids. The risk factors for
HIV infection are:
– History of receiving blood transfusions or clotting
factors.
– Unsafe sexual practices.
– Infant born to a mother with HIV infection (vertical
transsion).
– Intravenous drug use (IDU) in which syringes are
shared among users.
Pathophysiology of HIV infection
Pathophysiology of HIV infection (Cont’d)

Primary infection
• Early symptoms of HIV infection are nonspecific and
may include fever, sore throat, swollen lymph nodes,
skin rashes, muscle and joint pain, and diarrhea (flu-
like symptoms).
• After these symptoms subside, many people remain
symptom-free for 5 ~10 years or even longer until
progression to AIDS.
Pathophysiology of HIV infection (Cont’d)

AIDS-defining illnesses
• If the HIV infection is not treated, the depletion of
CD4+ T cells (less than 200/uL) increases the
patient’s susceptibility to:
– opportunistic infections: Infections caused by
microorganisms that normally do not cause
disease in healthy individuals.
– Cancers: Kaposi’s sarcoma
– Weight loss and wasting
Medical diagnosis of HIV infection

CD4 level categories

+: CD4 category 3 is criteria for the diagnosis for AIDS.

Medical diagnosis of HIV infection (Cont’d)

Clinical categories (A, B)

Medical diagnosis of HIV infection (Cont’d)

Clinical categories (C)

+: Clinical category C is criteria for the diagnosis for AIDS.

Consequences of HIV infection

Body fat redistribution

• The complications, resulting from some of the
antiretrovirus drugs, include body fat redistribution,
abnormal blood lipid levels, and insulin resistance.
– Lipohypertrophy: Fat accumulation at abdomen,
(pot belly), at the base of the neck (buffalo
hump), at the breast (breast enlargement), and
benign growths composed of fat tissue
(lipomas).
– Lipodystrophy: Fat loss from face, arms, legs
and buttocks.
AIDS-related lipohypertrophy
• The accumulation of fatty tissue at the base of
the neck, referred to as buffalo hump.
AIDS-related lipodystrophy
Consequences of HIV infection (Cont’d)

Abnormal fat and glucose metabolism

• Some of the antivirus drugs can cause metabolic
abnormalities in 25~50% of the patients.
– Hypertriglyceridemia
– Elevated LDL cholesterol levels
– Low HDL cholesterol levels
– Glucose intolerance and hyperinsulinemia
Consequences of HIV infection (Cont’d)

Anorexia and inadequate food intake

• Emotional distress, pain, and fatigue;
• Oral infections: Common infections include thrush
and herpes simplex virus infection.
• Respiratory disorders: Pneumonia and tuberculosis
are common in PLWHA.
• Cancer: Kaposi’s sarcoma can cause lesions in the
mouth and throat that make eating painful.
• Medications: ARVs often cause anorexia, nausea
and vomiting, altered taste sensation, food
aversions, and diarrhea.
AIDS-related oral infection

• Thrush • Herpes simplex virus infection

Consequences of HIV infection (Cont’d)

Weight loss and wasting

• Also called AIDS-related wasting syndrome (AWS).
Significant weight loss (10% weight loss within a 6-
month peroid) occurs during opportunistic infection
or other events. AWS has many causes including:
– Anorexia and inadequate food intake;
– Malabsorption and chronic diarrhea;
– Diet-drug interactions;
– Hormonal deficiencies (testosterone or thyroid);
– Inflammatory cytokines.
Consequences of HIV infection (Cont’d)

GI tract complications
• Complications may result from opportunistic
infections, the HIV infection itself, and medications.
PLWHA face an extremely high risk of malnutrition
due to the combination of:
– Intestinal discomfort
– Bacterial overgrowth
– Malabsorption
– Nutrient losses from vomiting, steatorrhea, and
diarrhea.
Consequences of HIV infection (Cont’d)

Neurological complications
• Neurological complications: Clinical features include
dementia, muscle weakness and gait disturbances;
and pain, numbness, and tingling in the legs and
feet.
• Cryptococcal meningitis: a leading cause of death in
Africa. It is responsible for an estimated 15% of all
HIV-related deaths globally.
Consequences of HIV infection (Cont’d)

Other complications
• Anemia due to chronic inflammation;
• Skin disorders include rashes, infection and cancer;
• Eye diseases include retinal infection and
detachment;
• Kidney diseases such as nephrotic syndrome and
chronic kidney disease.
Treatment for HIV infection

Goals of treatment for HIV infection

• Although there is no cure for HIV infection,
treatments can help to slow its progression, reduce
complications, and alleviate pain. The
comprehensive treatment includes:
– Anti-HIV therapy: HAART
– Prevention and treatment for opportunistic events
and other co-conditions
– Nutrition therapy
Treatment for HIV infection (Cont’d)

HAART
• HAART: Acronym for “Highly active antiretroviral
therapy”, which combines three or more antiviral
drugs.
• Goals of HAART: to lower the viral load, maintaining
a level of less than 50 copies/mL in serial tests;
• Benefits of HAART: Slowing down the progression
and reducing the rate of mortality.
• Adverse effects of HAART: Including GI effects, skin
rashes, headache, anemia, tingling and numbness,
hepatitis, pancreatitis, and kidney stones.
Five categories of ARVs

1. NRTIs: nucleoside reverse transcriptase inhibitors

2. NNRTIs: non-nucleoside reverse transcriptase
inhibitors
3. FIs: fusion inhibitors
4. IIs: integrase inhibitors
5. PIs: protease inhibitors
Five categories of ARVs and their acting points
 Five categories of ARVs and their acting points

Common combinations of ARVs: 2 NRTIs+1 NNRTI or 2 NRTIs+1 PI.

Food-drug interactions for NRTIs
NRTI Abbrevation Requirement GI effects
zidovudine ZDV or AZT N/A Nausea

didanosine ddI Take without food Diarrhea, nausea

stavudine d4T N/A Diarrhea, nausea

lamivudine 3TC N/A Nausea

abacavir ABC N/A Nausea

Nausea,
Truvada N/A
Abdominal pain

• NRTIs in general can lead to anemia, anorexia, low

VitB12, Cu, Zn, and carnitine.
Food-drug interactions for NNRTIs
NNRTI Abbrevation Requirement GI effects
Take with acidic
delavirdine DLV
beverage
Avoid taking with
efavirenz EFV Diarrhea
high-fat meal
Take on an empty
efavirenz stomach before
going to sleep
navirapine NVP N/A Nausea

tenofovir TDF N/A Diarrhea, nausea

• NNRTIs in general can lead to fat maldistribution,

hypertriglyceridemia, hyperglycemia (DLV), and liver
toxicity (NVP).
Food-drug interactions for PIs (1)
PI Abbrevation Requirement GI effects
Avoid taking with
amprenavir APV Nausea
high-fat meal
atazanavir ATV Take with food

darunavir TMC114 Take with food

Take with lots of
indinar water, on empty Nausea
stomach
nelfinavir NFV Take with food Diarrhea
Food-drug interactions for PIs (2)
PI Abbrevation Requirement GI effects
ritonavir RTV Take with food Diarrhea, nausea

saquinavir SQV Take with food Diarrhea

Take with a full
tipranavir TPV meal, preferably Diarrhea
high-fat
fortovase FTV N/A

lopinavir LPV N/A Diarrhea, nausea

• PIs in general can lead to fat maldistribution,

hyperglycemia (APV, ATV), mouth/esophageal ulcers
(FTV), and metallic taste (indinar).
Food-drug interactions for FIs and IIs
FI or II Abbrevation Requirement GI effects
FIs

enfuvirtide T20 N/A

maraviroc N/A Diarrhea

II

raltegravir N/A Diarrhea, nausea

Treatment for HIV infection (Cont’d)

Control of lipodystrophy
• Physical activity: Both aerobic activity and resistance
training help to reduce abdominal fat.
• Cosmetic surgery.
• Alternative antiretroviral drugs: to alleviate
symptoms.
• Other medications: to treat abnormal blood lipid
levels and insulin resistance.
Treatment for HIV infection (Cont’d)

Control of anorexia and wasting

• Anabolic hormones: Testosterone and hGH,
combined with resistance exercises.
• Appetite stimulants: Megestrol acetate and
dronabinol are prescribed to stimulate appetite and
improve weight gain.
• Regular physical activity
Treatment for HIV infection (Cont’d)

Nutrition therapy
• Nutrition plays an important role in the
comprehensive HIV/AIDS treatment, which breaks
the vicious cycle of malnutrition and HIV-infection.
Treatment for HIV infection (Cont’d)

Nutrition therapy
• Nutrition assessment and counseling should begin
as soon as a patient is diagnosed with HIV infection.
– Dietary evaluation
– Anthropometric assessment
– Biochemical assessment
– Medical history
Treatment for HIV infection (Cont’d)

Nutrition therapy
• Nutrition diagnosis: Common problems include:

–Increased energy expenditure – Underweight

–Inadequate oral food/water intake
–Increased nutrients needs
–Impaired nutrients utilization
–Malnutrition
–Altered GI function
–Swallowing difficulty
– Altered laboratory value
– Food-drug interactions
– Physical inactivity
– Intake of unsafe food
Treatment for HIV infection (Cont’d)

Nutrition therapy
• Nutrition intervention: Goals for the nutrition care
plan may include:
– Restoration of adequate nutritional status
– Prevention of adverse events related to therapies
– Management of co-conditions (e.g., diabetes,
liver disease, renal dysfunction).
Nutrition intervention
• Weight maintenance: It is necessary to determine
the factors that interfere with the patient’s food
intake and physical activity, as well as offer
suggestions:
– High-energy, high-protein diets may be helpful;
– Additional nutrient-dense snacks can improve
intakes;
– Small, frequent meals are better for patients with
oral or GI problems.
Nutrition intervention
• Micronutrients: Multi-vitamin/mineral
supplementation is controversial! However, it should
be kept in mind:
– PLWHAs are more likely to develop nutrient
deficiencies due to reduced food intake,
malabsorption, diet-drug interactions, and nutrient
losses.
– Recommendation: maintaining intakes that are
close to the DRIs.
 Selected micronutrients in HIV infection
Nutrient RNI/AI UL Comments
VitA 700-900ug 3000ug Associated with immun function

Suggested along with VitB1 in cases

VitB2 1.1-1.3mg -
of lactic acidosis

Folic acid 400ug 1000ug Suggested in case of pregnancy

Low or excess intakes are
VitB6 1.5-1.7mg 100mg associated with peripheral
neuropathy
May be malabosorbed due to altered
VitB12 2.4mg -
stomach pH value

Reducing oxidative stress, but high

VitC 75-90mg 2000mg
doses may interact with ARVs

Potential for immunostimulation, may

VitE 15mg 1000mg
interact with amprenavir
 Selected micronutrients in HIV infection
Nutrient RNI/AI UL Comments
Do not recommend regular
Iron 8-18mg 350mg supplementation unless the threat of
anemia motality is imminent

Low or excess selenium values are

Selenium 55ug 400ug
associated with immune dysfunction

Zinc supplementation has been

Zinc 8-11mg 40mg associated with fewer opportunistic
infections
Nutrition intervention
• Metabolic complications: Treating ARVs-related
metabolic complications, such as elevated
triglyceride and LDL cholesterol, insulin resistance,
requires both medications and dietary adjustment.
– Achieve a desirable body weight;
– Limit intakes of trans fat, cholesterol, alcohol and
added sugar. Replace saturated fat with
unsaturated fats;
– Increase fiber intake;
– Regular exercises.
Nutrition intervention
• Symptom management: The discomfort associated
with HAART, opportunistic GI infections, and
malabsorption may make food consumption difficult.
The following issues are to be addressed:
– Appetite loss
– Nausea and vomiting
– Diarrhea
– Oral lesions
 Selected symptoms management
Symptom Recommendations

• Determine the cause of anorexia and

pursue treatment
• If significant weight loss occurs, consider
appetite stimulants (Megesterol acetae,
Appetite Dronabinol)
loss
• Refer to resources for food if food
insecurity is a problem
• Monitor nutrient intake, weight, and body
composition
 Selected symptoms management
Symptom Recommendations

• Determine the cause of nausea and

vomiting and pursue treatment
• If vomiting leads to chronic reduced food
Nausea
intake, evaluate for antiemetic
Vomiting medications
• Monitor food and food intake, fluid
status, weight
 Selected symptoms management
Symptom Recommendations

• Determine the cause of diarrhea and

pursue treatment
• Anti-diarrheal medications should be
considered for significant acute and
Diarrhea chronic diarrhea (Loperimidium,
Atropine, Kaopectate, Pancreatic
enzymes)
• Monitor fluid intake, hydration, weight,
and body composition
 Selected symptoms management
Symptom Recommendations

• Determine and pursue appropriate

treatment for oral lesions
• Consider topical medications to ease
Oral lesion
pain in eating and advise on good oral
hygiene
• Monitor food intake, weight
Nutrition intervention
• Food safety: PLWHAs have extremely high risk of
developing foodborne diseases.
• Water can also be a source of foodborne illness and
is a common cause of cryptosporidiosis in HIV-
infected individuals. They are encouraged to drink
filtered or bottled water, or boil drinking water for one
minutes.

Cryptosporidium parvum
Study questions
1. What is AIDS-related wasting syndrome? Explain the
common reasons for AWS.
2. Explain why an HIV infection often results in anorexia and
reduced food intake.
3. Discuss the features of medical nutrition therapy for HIV-
infected and AIDS patients.
4. Why are people with HIV infections highly susceptible to
foodborne illness? Describe some measures that can be
taken to prevent foodborne illness.
Multiple choice
1. HIV can enter and destroy these immune cells:
a. neutrophils
b. B cells
c. natural killer cells
d. helper T cells

2. HIV-lipodystrophy syndrome may result in all of these

changes except:
a. fat accumulation at the base of the neck.
b. hypertriglyceridemia.
c. increased abdominal fat.
d. increased fat in the arms and legs.
3. Mouth sores in people with HIV infections are most
frequently due to:
a. oral infections.
b. dehydration.
c. nutrient deficiency.
d. foodborne illnesses.
4. To prevent cryptosporidiosis, a person with HIV
infection may need to:
a. wash hands carefully before meals.
b. avoid consuming undercooked meat and eggs.
c. consume a high-kcalorie, high-protein diet.
d. boil drinking water for one minute.
5. Megestrol acetate and dronabinol are:
a. protease inhibitors that fight HIV infection
b. anabolic hormones that promote gain of muscle tissue
c. medications used to promote weight gain
d. medications that treat common opportunistic
infections
Case study #1
• Josh is a 31-year-old hospital porter. He lives with his
partner in a small flat near the hospital. He was found to
be HIV positive following a short period of flu-like illness in
2001. He pays a lot of attention to his general health, and
takes supplements, evening primrose oil and gingko
biloba. He is also a keen runner.
Case study #1(cont’d)
• Josh has started to feel a little tired and weak; he has
become snappy and irritable. He complains of a dry,
rough mouth and has developed watery diarrhoea which
he voids about six times a day. He has night sweats and
fever. He has virtually no appetite and the small amount
of food that he does consume makes him feel sick.
• Josh has lost about 5 kg in weight over the past four
weeks. At clinic today he was told he had developed
cryptosporidiosis infection. The doctor also told him to pay
more attention to his diet. He refers him for dietary advice.
He is 181 cm tall (61 kg) and has a CD4 count of 190.

Clinical cases in dietetics. © 2008 by Fred Pender. First published 2008 by

Blackwell Publishing Ltd
Questions to consider
1. What does a CD4 count tell us?
2. Explain the significance of the signs and symptoms in the
context of Josh’s worsening nutritional status.
3. Formulate the short-term nutritional goals that may be
appropriate for Josh and explain and justify the approach
that may be taken at clinic.
Commentaries
1. The CD4 count of <200 makes the patient more
susceptible to infections.
2. Initial thoughts about the case are that the symptoms are
typical of an infection. Baseline information of diarrhoea,
fever and night sweats indicates the need to increase fluid
requirements; dry rough mouth is characteristic of
dehydration and infections mean a heightened
inflammatory response.
Commentaries
3. Short-term goals are guided by the possibility of clinical
malnourishment (7% weight loss over four weeks) and the
need for nutritional support. Hydration is a priority
together with salt replacement in view of the diarrhea
(electrolyte replacement therapy). Antiemetic medication
may assist with the nausea and nutritional supplements
should commence in view of nutritional status. The
selection of supplement will be determined by tolerance
and diarrhoea. If the diarrhoea worsens, there is a need to
consider a semi-elemental sip feed. Depending on the
tolerance to oral diet and fluids, the patient may need to
be considered for nasogastric tube feeding.
Case study #2
• Ray E. is a 49-year-old Caucasian male who has been
HIV positive for approximately 14 years. He presented to
his physician with complaints of abdominal discomfort and
heartburn related to his enlarged abdomen. His doctor
previously diagnosed Mr. E with lipodystrophy syndrome
based on physical examination and insulin resistance. He
was referred to the dietitian for recommendations for
nutrition-related interventions.

Nutrition Therapy and Pathophysiology. Marcia Nelms,Kathryn Sucher, Sara Long

Nutrition Assessment:
Ht. 179 cm Wt. 93 kg.
Abdominal circumference: 104 cm, abdominal skinfold: 3 mm

Labs:
Viral load: undetectable (below 50 copies per mL), CD4+
count: 660/μL

Medications:
Currently taking efavirenz and combovir (lamivudine and
zidovudine), previously taking lopinavir/ritonavir and
combovir, just prescribed rosiglitazone/metformin
combination.
Medical history
• The registered dietitian’s interview indicates that the
patient describes gaining weight quickly over the last six
months, and most appears to be in the abdomen.
Heartburn began in the last few weeks and he is
concerned about his body shape. He stopped
exercising regularly about a year ago after he moved to
the suburbs and away from his usual gym.
Dietary Intake
AM: scrambled eggs with sausage and toast, orange
juice, coffee;
Mid-day: meatloaf sandwich with cheese or gravy dipped
Italian beef with cola;
PM: casserole with bread or rolls and water. Snacks
throughout the day are typically potato chips or crackers.
Drinks 3 large mugs of coffee and 1–2 colas throughout
the day. Partner cooks large meals for family and friends
on weekends.
Questions to consider
1.What role might Mr. E’s insulin resistance play in his
current concern for fat accumulation and heartburn?
2.What potential effect does each of his previous and
current medications have on lipodystrophy and insulin
resistance?
3.What parts of his diet history appear to put him at risk
for or exacerbate lipodystrophy and heartburn?
4.Identify and prioritize nutrition-related problems.
Questions to consider
5.What-diet related recommendations would you discuss
with this patient? Include diet recommendations to
support medications.
6.What non-nutrient recommendations would you suggest
that this patient, his physician, and his health care team
explore in order to improve lipodystrophy-related
discomfort and heartburn?
7.What criteria would you monitor in this patient for
improvement?