HIV/AIDS and Nutrition Ali Aziz, Aurielle Lowery, Sarah Vacher,

HIV/AIDS and Nutrition

Ali Aziz, Aurielle Lowery, Sarah Vacher, Tessa Englund, and Xiaolu Hou

Source: http://hiv.health.gov.tt/

Objectives

Examine HIV’s history, etiology, & effects on the human bodyExplain the impact of HIV on nutritional status & vice versa Discuss nutrition assessment methods for an HIV patient

Identify nutrition diagnoses for the case patient & other common diagnoses for HIV/AIDS patients

Identify nutrition interventions for HIV/AIDS patients

Discuss common goals/outcomes as well as time frames

for nutrition monitoring & evaluation

Use a male case patient with AIDS-Stage 3 with oral thrush

to facilitate more detailed exploration of the topics above

Case Patient T.L.

32-year-old African American male, 6’1”, 151# CBW, and 160-165# UBW HIV diagnosed 4 years ago but had never been treated for it PTAAdmitted with very sore mouth/ throat, likely PNA & progression

to AIDS, mild malnutrition, & 8.5% weight loss compared to UBW.

Diagnosis of AIDS-Stage 3 with thrush & no clinical evidence of PNA. HAART initiated with Atripla.

Sources: http://remediesforthrush.blogspot.com/2013/09/oral-thrush-infection-and-solution.html

http://recommendpills.com/candidiasis-symptoms-and-treatment/04/11/2012/

HIV/AIDS and Nutritional Status

The first cases of AIDS were described in 1981. Soon after, HIV was identified as leading to AIDS.At the end of 2008 an estimated 33.4 million people lived with either AIDS or HIV.

Epidemiology and Trends

Acquired immune deficiency syndrome (AIDS) is caused by Human Immunodeficiency virus (HIV) .

HIV affects the body’s ability to fight off infection and disease.

Nutritional status plays an important role in maintaining a healthy immune system.

HIV Transmission

HIV is transmitted via direct contact with infected fluidsBlood, semen, pre-seminal fluid, vaginal fluid,

breast milk

Cerebrospinal fluid, synovial fluid,

amniotic fluid

Sexual transmission is most common

Saliva, tears, and urine do NOT contain enough HIV for transmission

Source: http://www.prideglv.org/how-do-you-get-hiv/

HIV-1 vs HIV-2

HIV-1 infection is what we are referring to unless specified otherwiseHIV-2 is endemic in West Africa

Lower viral loads, longer asymptomatic period, lower mortality

rates than HIV-1

Rarely seen outside of Africa or areas with strong ties to affected areas in Africa

Sources: http://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/24/hiv-2-infection

http://jack-wi-sept2012.wikispaces.com/AIDS+in+Africa+-+Linda

Stages of HIV Infection

HIV progresses through four clinical stagesAcute HIV infection

Clinical Latency

Symptomatic HIV infection*

Progression of HIV to AIDS*

Two main biomarkers to assess disease progression

HIV RNA (viral load)

CD4 (T-helper cell) count

1: Acute HIV I

nfectionTime from transmission of HIV to the host until production of detectable antibodies

This is called seroconversion

Non-specific clinical features and very short diagnostic window

Acute HIV infection is rarely discovered

2: Clinical Latency

Also called asymptomatic HIV infection

Further evidence of illness might not show for as long as 10 years post-infection

Virus is active and replicating at a slow rate

Long-term non-progression

Here CD4 count levels remain WNL and viral loads can be undetectable for years

Not everyone experiences clinical latency for so long

3: Symptomatic HIV infection

Over time HIV breaks down the immune system and the body is incapable of fighting off the virusHere CD4 counts fall below 500 cells/mm

3

Pt likely to develop s/s

Persistent fevers, chronic diarrhea, unexplained weight loss, recurrent fungal or bacterial infections

4: Progression of HIV to AIDS

Immunodeficiency continues to worsen and CD4 counts fall lowerIncreased risk of opportunistic infections (OIs)

CDC defines AIDS as:

L

ab confirmation of HIV infection in person with a CD4+ count below 200 cells/mm

3

(or less than 14%)

Documentation of an AIDS-defining condition

Krause, pg 866, Box 38-1

Case Study Patient

Pt believes HIV has progressed to AIDS because he is experiencing: exhaustionsore mouth and throat (thrush)unintended weight loss

possible pneumonia diagnosis

Source: http://www.cell.com/cms/attachment/531402/3640755/gr2.jpg

Opportunistic Infections

Candidiasis of bronchi, trachea, esophagus, or lungs - infection caused by yeast (commonly known as thrush)Cryptococcosis - parasitic infection in small intestineCryptosporidiosis - chronic intestinal infection

(greater than 1 month's duration)

Tuberculosis

- bacterial lung infection

Pneumonia

, recurrent

PCP

- form of PNA caused by fungus

These typically present themselves during

the symptomatic HIV infection stage.

Source: Mahan LK, Escott-Stump S, Raymond JL.

Krause's Food & the Nutrition Care Process

. 13th ed. St. Louis, MO: Saunders; 2012.

Other Common ComplicationsHALS

- HIV-associated lipodystrophy syndromeWasting - unintentional weight lossObesityKaposi’s sarcoma - cancerous connective tissue tumor (pictured)Lymphoma - blood cell tumorsHIV encephalopathy - neurodegenerative disorders (also called HIV-associated dementia)

Chronic liver disease

AIDS-Defining Conditions

Source: http://www.dermis.net/dermisroot/en/1270069/image.htm

Impact on Nutritional Status

Vitamin and mineral deficiencies are common Resultant of:malabsorption

drug-nutrient interactions

altered metabolism

altered gut & gut barrier function

Commonly low:

Vitamin A, zinc, and selenium

Impact on Nutritional Status

Low levels of vitamin A, vitamin B12, and zinc are associated with faster disease progressionHigher intakes of

vitamins B and C have been associated with increased CD4 counts and slower disease progression

No evidence that megadosing is helpful

Case Study Patient - Vitamins

Pt diet should be assessed to ensure that he is receiving DRI’s, especially for:Vitamin B12Vitamin A Vitamin E

Vitamin D

Selenium

Zinc

Iron

Because pt is a “picky eater” and has mouth sores that make eating uncomfortable, RD needs to work with him to get adequate nutrients while being sensitive to preferences/pain.

CD4 Count

Indicator of immune function & stage of HIV infection

Used to determine

whether to initiate

antiretroviral

therapy (ART)

, which suppresses viral loads to increase quality of life and reduce

M&M

Case patient has low T-helper cell counts (CD4) indicating immune suppression and progression to AIDS.

Source: http://www.bio.davidson.edu/Courses/Molbio/MolStudents/spring2003/Cobain/geneprotein.html

Treatment Types: HAART HAART =

Highly Active Antiretroviral Therapy (also commonly referred to as ART) Goals: Reach and maintain viral suppressionReduce HIV related M & M

Increase quality of lifeGain and maintain immune function

Classes of Antiretroviral Drugs

Nucleoside and nucleotide reverse transcriptase inhibitors (NRTIs)Nonnucleoside reverse transcriptase inhibitors (NNRTIs)Protease inhibitors (PIs)Fusion inhibitors

CCR5 (chemokine receptor 5) antagonists

Integrase strand transfer inhibitors (INSTIs)

Most common treatment is the

combination of NRTIs + NNRTI

or

PI

Predictors of Adherence

Patients must have the ability and commitment to a lifelong treatmentUnderstanding of the pros and cons of therapy and importance of adherenceBarriers include:homelessness

low literacy level

depression

dementia/psychosis

illicit drug use

ART Side Effects

ART medications commonly cause the following side effects:diarrhea fatiguegastroesophageal reflux

nauseavomiting

dyslipidemia

insulin resistance

Many ART drugs must be taken on a strict schedule, with or without food. Consider this when evaluating patient lifestyle, willingness to take medication, and access to health care.

Source: http://www.pwnfitness.com/harmful-dangerous-side-effects-zinc/

Drug-Nutrient InteractionsBe aware of patient’s

medications, vitamins & supplements, and recreational substances consumed/used in order to prevent interactions with ART. Ex: Grapefruit juice and protease inhibitors (PIs) both compete for cytochrome P450 enzyme. Grapefruit consumption can lead to either increased or decreased blood levels of the drug.

Tables 38-2 through 38-5 in the Krause textbook

break down specific drugs, interactions, and side effects.

Source: www.lovewithlife.com

Cost of Therapy

According to the CDC treatment usually costs $2000 - $5000 a month About half of those diagnosed with HIV do not have regular health care42% are on Medicaid & 24% are uninsured

For the uninsured many will qualify for theAIDS Drug Assistance Program

Many states have an income cutoff of about $22,000/year

Estimated survival time of 24.2 years after HIV diagnosis yields the following costs:

Lifetime on discounted treatment: $385,200

Lifetime without discount: $618,900

Source: http://blogs.scientificamerican.com/observations/2011/01/12/cost-of-cancer-care-projected-to-jump-nearly-40-percent-by-2020/

Cost Breakdown

Just FYI...HIV/AIDS costs the US about $12 billion annually in health care-related expenses!ART Drugs 73%

Inpatient Costs 13%

Outpatient Costs

9%

Other HIV-related

Medication & Lab Costs

5%

Nutritional ImplicationsRDs need to take into consideration:

Medications Disease Complications & CombinationsImmunity

Quality of LifeAltered Metabolism

Dietary Habits

Health Care Access

Energy Expenditure

Research suggests that patients may have up to a 10% increase in resting energy expenditure in asymptomatic HIV patients. That number can rise to up to 20 - 50% after an opportunistic infection (OI). Opportunistic Infections: These infections take advantage of a weakened immune system. Those with immuno-deficiencies can face serious threats from viruses and other microbes that healthy individuals would not even experience symptoms from.

Source: http://www.healthline.com/health-slideshow/hiv-opportunistic-infections

Nutrient Breakdown

PROTEIN: DRI of 0.8 g/kg IBW is recommended for healthy or asymptomatic individuals, however it should increase if REE is calculated at an increased rate.Also increase by 10% after an OI FAT/CHO: Keep intake relative to total calories. There is evidence to support increasing Omega-3 fatty acids in the diet and keeping saturated fats low.

MICRONUTRIENTS: There is NO evidence to support doses of micronutrients

above

the DRI.

It is important to monitor individual nutrients and to do so on a patient-by-patient basis

Special Considerations: Wasting, Obesity, & HALS

Wasting: unintentional weight loss and loss of LBM which are associated with disease acceleration and mortality. Caused by a combination of possible factors such as poor dietary intake, nutrient malabsorption, increased metabolic rate, or various other metabolic complications. Case Pt: Recent undesired weight loss of 6-9% UBW (9-14 lb.)Obesity: some ART medications increase risk of hyperlipidemia, insulin resistance, and diabetes. Monitor these values and encourage both aerobic and resistance training activities.

HALS: HIV-Associated Lipodystrophy Syndrome

HALS refers to the abnormalities in fat distribution similar to metabolic syndrome. Fat accumulation in the abdominal or dorsocervical region are common. Fat atrophy in the extremities, face, and buttocks are also common.

Nutritional Implications of HALS

Common problems associated with HALS include: Insulin Resistance HyperglycaemiaDyslipidemiahigh total cholesterol and triglycerides, lowered HDL cholesterol, elevated LDL cholesterol

Type II diabetes mellitus

Nutritional interventions should be targeted towards patients

individual

symptoms and problems. There are no current major nutritional treatments for the lipodystrophy itself, but increasing

fiber intake

and

physical activity

may offer slight benefit.

Examples of HALS

Source: http://www.nature.com/nrendo/journal/v8/n1/images/nrendo.2011.151-f2.jpg

http://1.bp.blogspot.com/-ewQ6BFHZA6o/T-UahEZ-KFI/AAAAAAAAfwA/-4HonrykycM/s640/collage1.jpg

Case Patient Information for Nutrition Diagnoses

32-year-old African American male, 6’1”, 151# CBW, and 160-165# UBW HIV diagnosed 4 years ago but had never been treated PTA

Admitted with very sore mouth/ throat, difficulty eating, likely PNA & progression to AIDS,

mild malnutrition

, &

recent 6-9% (9-14 lb.) weight loss

from UBW.

Diagnosis of AIDS

-Stage 3 w/ oral thrush & no evidence of PNA.

HAART initiated.

Sources: http://remediesforthrush.blogspot.com/2013/09/oral-thrush-infection-and-solution.html

http://recommendpills.com/candidiasis-symptoms-and-treatment/04/11/2012/

Case Patient Information for Nutrition Diagnoses

32-year-old AA male151# (69 kg) CBW,160-165# (73-75 kg) UBW, 6’1” (185 cm)Family hx of CAD & HTN

EEN:

2360-2740 kcal/d

(MSJx1.4-1.5,

rebuild LBM/infection)

100-125 g protein/d

(1.2-1.5 g/kg IBW)

2,398 mL fluid

(35 ml/kg/d)

24-hr recall shows intake of ~2,000 kcal & 71 g protein

HAART regimen Atripla w/ side efx including N/V/D; anorexia; dysgeusia; increased cholesterol & TG; & known interaction w/ alcohol, SJW, garlic, & milk thistle

PTA took MVI, vit C & E, ginseng, milk thistle, & echinacea supplements

2-3 beers 3-4 times/week

Nutrition Diagnoses for Case Patient

Sample PES Statements for Patient T.L.Unintended weight loss (NC-3.2) r/t inadequate oral intake and mouth pain AEB caloric intake ~73-85% of EEN according to 24-hr recall; mild malnutrition (82% IBW); and recent undesired significant weight loss of 6-9% (9-14 lb.).Predicted food-medication interaction (NC 2.4)

r/t concurrent use of Atripla, alcohol, milk thistle, and St. John’s wort AEB pt report of regular alcohol consumption and herbal supplementation along with recent initiation of HAART using Atripla (which has known DNIs with alcohol, milk thistle, SJW).

Food and nutrition-related knowledge deficit (NB-1.1)

r/t lack of prior nutrition-related education AEB self-reported usual dietary intake (before mouth sores) high in processed foods and low in fresh nutrient-dense foods; high alcohol consumption; and

excessive vitamin C and E supplementation.

Common Nutrition Diagnoses for HIV/AIDS Patients

Inadequate oral intake (NI-2.1) Inadequate protein-energy intake (NI-5.3)Increased energy expenditure (NI-1.1)

Increased nutrient needs (NI-5.1)

Malnutrition (NI-5.2)

Unintended weight loss (NC-3.2)

Swallowing difficulty (NC-1.1)

Altered GI function (NC-1.4)

Predicted / Food-medication interaction (NC-2.4 or NC-2.3)

Altered nutrient-related laboratory values (NC-2.2)

Food and nutrition-related knowledge deficit (NB-1.1)

Limited access to food or water (NB-3.2)

Nutrition Interventions for Case Patient

Adjust meals to a texture modified diet (ND- 1.2) to ease pain from oral thrush and mouth sores by recommending soft foods (prepared mashed, pureed, or cooked until very soft). Refer pt to another provider (ND-1.5) for treatment of oral thrush, likely with antifungal medication.

Promote a general/healthful diet (ND-1.1)

with small, frequent meals to prevent further weight loss and promote weight regain to achieve IBW of 184# or at least UBW of 160-165#.

Nutrition Interventions for Case Patient

Refer pt to another provider (or community program if necessary) (ND-1.5; ND-1.6) if necessary to decrease alcohol intake & receive more education on living with AIDS. Instruction intended to lead to nutrition-related knowledge. Purpose of nutrition education (E-1.1) should be to improve pt’s food choices to improve PO intake toward meeting EEN; minimize DNIs w/ current medications; and stop excessive supplementation & alcohol consumption.

Nutrition Interventions

Highly individualized: Very important to tailor intervention to pt needs using clinical judgment & collaborating w/ team of healthcare providers!Energy/nutrient needs:

NO specific nutrition therapy for HIV/AIDS except for meeting additional energy, protein, fluid, & micronutrient needs.

Specific diet/recommendations:

Diet adjustments & nutrition counseling often needed to

manage HIV/AIDS complications & comorbidities

such as:

Cardiovascular disease/risk

Liver or renal disease (

e.g.

, hepatitis B & C)

Diabetes, insulin resistance, and/or altered sex hormones

Nutrition Interventions

Provide adequate nutrition/reduce or eliminate malnutritionPRIORITY of treatment to prevent weight loss/wastingnecessary for body to properly process meds & nutrients

may significantly slow progression to AIDS

decrease disease severity, maintain immune fxn, improve lifespan & quality of life

can be challenging to balance important health priorities

Minimize drug-nutrient interactions

many drugs need to be taken w/ regard to food

common HAART side efx of N/V/D, anorexia, dyslipidemia

potential interactions w/ alcohol, grapefruit, supplements

Source: "Position of the American Dietetic Association: nutrition intervention and human immunodeficiency virus infection." JADA 110.7 (2010): 1105-1119.

Nutrition Interventions

Management of N/V/D Small, frequent lower-fat meals w/ snacksReplenish fluids & nutrients when lost

Avoid lying down within 1 hour of eating

Limit or avoid lactose, caffeine, & insoluble fiber

Nutrition supplements and medication as needed

Adjunct Therapies

Common Medications:

antiemetic, antidiarrheal, appetite- stimulating, lipid-lowering, antidiabetic, anabolic, & pain

Exercise:

maintain/increase LBM, promote healthy BMI &

body shape, & promote CV health

Sources: http://coveville.com/how-to-get-rid-of-diarrhea/

Nutrition Care Manual

Nutrition Interventions

Education & CounselingGeneral nutrition & PA principlesFood safety & access issues

Meal preparation, timing, & content

Medical adherence & potential DNIs

Micronutrient supplementation

Body image & changes to body weight/shape

Other psychosocial issues

Referral to Other Providers

Last but NOT least...this is key to any plan of care

for HIV/AIDS patients!

Sources: http://www.school-counselor.org/topics/new-school-counselor.html

Nutrition Care Manual

Nutrition Support

Enteral nutrition (EN) & parenteral nutrition (PN) support are both viable options for HIV/AIDS patients if needed.Criteria for initiating either EN or PN remain the same as for other disease states & ASPEN Guidelines should be followed.“If the gut works, use it!” still applies here...even when PN has been initiated, it is important to stimulate the gut regularly with water & a little food if at all possible to prevent GI dysfunction & reduce risk of bacterial translocation.

Catheter infection & refeeding syndrome are the primary risks of NS but minimized with proper monitoring & adjustment.

Especially for highly immunocompromised HIV/AIDS patients, additional sanitary precautions including the use of sterile water may be needed to reduce risk of infection.

Nutrition Monitoring & Evaluation

Nutrition reassessments should generally be carried out at least every 3-6 months in HIV/AIDS patients.Treatment for this population is highly individualized, so F/U may be appropriate sooner than 3 months depending on the initial nutrition assessment, diagnosis, & intervention.

During reassessments, it is important to monitor:

Food intake

Body weight, distribution, & composition

Anthropometric measurements can help identify HALS even when weight is stable!

Pertinent lab values

Medications

Supplements

Nutrition M&E for Case Patient

Monitor weight over next 2 monthsEncourage 0.5-1 lb. weekly weight gainTarget weight 184 lb. (acceptable range is 166-202 lb.)With changes and disease progression, monitor & evaluate:

Food intake

Lab values

Body composition

Medications

Supplements

Ensure that education is continual and appropriate

M&E should take place at least semiannually after initial F/U