December is HIV/AIDS awareness month, so what better time than now to dive into the nutritional management of these conditions. This article will aim to provide a “cheat sheet” of sorts about HIV/AIDS and how nutrition therapy can help diagnosed individuals manage their condition.
A little background about HIV/AIDS
HIV, which stands for Human Immunodeficiency Virus, is a sexually transmitted infection that can be spread by contact with an infected person's semen, vaginal fluids, or blood. It affected an estimated 62,050 Canadians in 2018, or 167 in 100,000 Canadians. In 2019, 2,122 Canadians received HIV diagnoses (~6 per 100,000 people). In general, prevalence rates have remained relatively stable in the last decade.
Although the prevalence of this condition is low, an estimated 13% of the total Canadians with HIV in 2018 went undiagnosed, thus were not receiving treatment. If left untreated for the long-term, HIV can develop into AIDS (Acquired Immunodeficiency Syndrome) within 8-10 years. A diagnosis of AIDS indicates severe immune system damage; however, with much improved antiviral treatments, most people with HIV don’t develop AIDS.
Complications
An HIV infection weakens the immune system as it targets and destroys CD4 T cells (the white blood cells vital for maintaining a strong immune system). Of course, this makes those with HIV/AIDS more susceptible to infections, like candidiasis, tuberculosis, cytomegalovirus, and more.
In addition, those with HIV/AIDS are more susceptible to lymphomas and Kaposi's sarcoma. Other complications include HIV-associated neurocognitive disorders, HIV-associated nephropathy, liver disease and wasting. This is where nutrition can play such an essential role in supporting those with HIV/AIDS, whether symptomatic or not.
The Main Nutrition Considerations for HIV/AIDS Management
In 2003, the World Health Organization released a report outlining the nutrient requirements for those living with HIV/AIDS. The following is a summary that is broken down by the main nutrition considerations, of which the American Dietetic Association, Dietitians of Canada and Ontario HIV Treatment Network (OHTN) are also in agreement with:
Malnutrition
Malnutrition, independent of HIV infection, can decrease immune function and lead to various deficiencies ranging from anemias to protein-energy malnutrition. It is crucial that the patient understands the need for weight and body store maintenance for their survival; greater weight and body store loss has shown to be directly related to a poorer prognosis for survival.
Malabsorption
Metabolic changes and malnutrition (especially starvation-related malnutrition) can be detrimental to patients' nutrition status. The reason for starvation may be multifactorial, such as financial concerns. food insecurity, anorexia, possible drug use, limited nutrition knowledge, inadequate oral intake, malabsorption, among many others. Fat malabsorption seems to particularly occur in this population, often accompanied by diarrhea and other typical symptoms.
Therapeutic Interactions
A common treatment for HIV is Highly Active Antiretroviral Therapy (HAART). It has worked amazingly to treat HIV and prolong (and even prevent) its possible development to AIDS. However, many reports of altered patterns of body composition (ex. peripheral fat loss), elevated blood lipids (dyslipidemia), altered insulin sensitivity or glucose dysregulation, lactic acidosis and mitochondrial toxicity have been made, for which medical teams must monitor.
Recommended Nutrition Interventions
The same standard assessment data is necessary for evaluating nutrition status in those with HIV/AIDS: anthropometry and physical exam, biochemical data, client history, dietary history, estimated needs, etc. When it comes to intervening, of course nutrition care should be personalized to each patient. In general, however, here are some guidelines from the Academy of Nutrition and Dietetics (AND) and OHTN for basing your nutrition intervention:
Energy needs: Patients' REE may be up to 10% higher in asymptomatic individuals regardless of treatment. Symptomatic HIV (ex. periods of hypermetabolism) may increase energy needs by 20-30%; however, further research is needed specific to HIV infection.
Protein needs: Due to the nature of HIV and its influence on metabolism plus the risk of malnutrition, a suitable protein target may be between 1.2-1.5 g/kg/day, with consideration to the patient's current status.
Macronutrient composition: Fair evidence suggests that patients' macronutrient composition follows the DRIs of 45-65% of calories from carbs, 10-35% from protein, 20-35% from fat. Fibre intakes should follow the standard recommendations as well.
Macronutrient composition and hyperlipidemia: strong evidence suggests patients may benefit from fat being 25-35% of calories (with emphasis on omega-3s), with <7% from saturated fat, <1% from trans fats, and <200mg of daily cholesterol.
Micronutrient needs: Strong evidence suggests that if those with HIV struggle to meet RDAs for micronutrients, supplementation should be recommended, especially for calcium and vitamin D.
Malabsorption/diarrhea: Fair evidence suggests the encouragement of the consumption of soluble fibre, medium-chain triglycerides, electrolyte beverages, and limiting the foods that exacerbate the diarrhea.
Achieving adequate calorie, protein and micronutrient intakes to maintain and restore bodily (especially immune) function can be essential for this population. During asymptomatic periods, a priority should be to regain any weight lost.
With that, a high energy, high protein diet may be required for improving outcomes, especially for symptomatic HIV infections. It may also be helpful to discuss specific nutrients that support immune function (like omega-3 fatty acids) that alter inflammatory responses in the body.
As usual as well, encouraging physical activity can be helpful for patients' health status, especially for maintaining or building muscle reserves (so long as it is not contraindicated). Strong evidence suggests benefits from >20 min/d of aerobic and/or resistance exercise three times a week.
Finally, due to the nature of the virus and its impact on immune health, it is exceptionally important that patients are aware of food and water safety protocols. People with HIV/AIDS have a higher susceptibility to foodborne illness, thus proper education is essential for its prevention.
The Bottom Line
Overall, further nutrition research regarding the care of those with HIV/AIDS is essential. However, based on current evidence, as well as the effectiveness of HAART, the nutrition management of patients with HIV/AIDS may be similar to that of other patients.
Sometimes, treating any underlying conditions is all that can be done; however, when symptomatic, this can be a challenge. Interventions should be individualized and follow-up should be dependent on their current status (see page 1 of the AND article linked above for more specific follow-up guidelines).
To conclude, adequate nutrition is essential for those with HIV/AIDS, so I hope this article provided a solid foundation for any patients you may have. Comment below if you have any questions you'd like answered!
-Justine Chriqui, RD, MScA