Human immunodeficiency virus (HIV) infection is a complex illness caused by a retrovirus, which is a single-strand virus that replicates by using reverse transcription to produce copies of DNA that become incorporated within the genome of the host cell. The HIV virus destroys a type of white blood cell known as CD4+ T lymphocyte, or T helper cell. These cells are important in maintaining the various functions of the human immune system. When the level of CD4+ T cells in the bloodstream falls, the patient loses the ability to fight off bacteria, viruses, and fungi that would not cause disease in a person with a strong immune system. Infections that occur in people with weakened immune systems are called opportunistic infections.
Acquired immunodeficiency syndrome (AIDS) is an advanced form of HIV infection in which the patient has developed opportunistic infections or certain types of cancer and/or the CD4+ T cell count has dropped below 200 per microliter. According to the Centers for Disease Control and Prevention (CDC), more than 1.1 million people in the United States were living with HIV/AIDS at the end of 2015, the most recent year for which data are available. Of these people, an estimated 15%, or one in every seven, were undiagnosed and unaware that they were infected. An estimated 36.7 million people around the world were infected with HIV as of 2016, with approximately 1.8 million new infections over the course of the year. The disease causes nearly 1 million deaths worldwide each year, 95% of them in developing countries. Sub-Saharan Africa is the region most severely affected.
Nutritional issues are common in patients with HIV infection. Some problems with diet and nutrition are caused by HIV infection directly whereas others are related to opportunistic infections or medication side effects. The current epidemic of opioid abuse in North America is another reason for poor nutrition in patients with HIV infection, as many addicts often spend whatever money they have on drugs rather than food.
Maintaining adequate food and energy intake and avoiding micronutrient inadequacies in patients with HIV infection is complicated not only by the many ways in which the disease can affect the body, including the fact that the virus mutates rapidly, but also by frequent updating of treatment strategies for AIDS, including nutritional therapy. As a result, nutritional care of patients with AIDS must be tailored to each person and reviewed carefully every few months. In 2010, the Academy of Nutrition and Dietetics issued a set of guidelines on the care of people with HIV infection that recommended appropriate nutritional care for individuals with HIV/AIDS. That publication is available on the Academy website.
AIDS is a relative newcomer to the list of major infectious diseases. According to the National Institutes of Health (NIH), researchers think that HIV originated in a species of chimpanzees native to west equatorial Africa and jumped the species barrier into humans through hunters' contact with the blood of infected chimpanzees, most likely somewhere in western Africa in the second half of the twentieth century. The earliest known case of HIV infection was found in a blood sample collected from a man in Kinshasa in the Congo in 1959.
Prior to 1996, nutritional management of AIDS patients focused largely on prevention of weight loss and wasting, sometimes called the “slim disease.” After the introduction of highly active antiretroviral therapy (HAART) in 1996, however, nutritionists were confronted with a range of other dietary problems related either to the new drugs or to prolonged survival itself. HAART is not one drug but a combination of various antiretroviral agents given to patients to prevent the virus from replicating and to discourage mutations of the virus. The drugs must be taken in combination because no medication by itself is able to suppress HIV for very long. One early problem with HAART was the complicated dosing schedules of the different drugs prescribed for an individual patient. To encourage adherence to treatment schedules (which must be at least 98% complete to protect the patient from developing a strain of the virus resistant to HAART), some pharmaceutical companies developed fixed-dose combinations. A fixed-dose combination is a medication in which several antiretroviral drugs that are known to work well together are combined in a single pill.
Guidelines for offering antiretroviral treatment (ART) to patients were published in the late 1990s because the drugs have so many adverse effects (including hair loss, muscle cramps and pains, kidney or liver failure, insomnia, inflammation of the pancreas, dizziness and mental confusion, headache, nausea and vomiting, and numbness in hands or feet) that many patients were not compliant with dosage schedules and developed drug-resistant mutations of the HIV virus. Recommendations for ART have been revised several times by the U.S. Department of Health and Human Services (HHS). The most recent version of the guidelines was issued in 2014, discussing every aspect of antiretroviral care for HIV patients, including laboratory testing for initial assessment of a patient's HIV status; treatment goals; therapy recommendations for patients without earlier treatment and with earlier treatment regimens; treatments that are not recommended; antiretroviral treatments in patients with other medical issues; limitations to safety and efficacy of various treatments; and preventing secondary infections of HIV. The primary recommendations for treatment standards for antiretroviral therapy as provided in the 2014 guidelines include the following:
It is this set of guidelines for ART that nutritionists currently work with when planning healthful diets for patients with HIV infection and AIDS.
Although no standard “HIV diet” or “AIDS diet” has been established because patients' symptoms, medication regimens, and corresponding nutritional needs vary so widely, registered dietitians who work with doctors and other healthcare professionals to care for these patients follow certain general practices.
The next step in the initial assessment involves the patient's completion of a food intake record (FIR). The patient is asked to record everything that is consumed in a 24-hour period, including snacks and alcoholic beverages. If possible, the patient will fill out two food intake records, one for a working day and one for a weekend day or holiday. The food record allows the dietitian to evaluate the patient's usual eating habits, portion sizes, food preferences, and average calorie intake. It also establishes a baseline for the individual patient, so that loss of appetite later on or other nutritional problems can be detected as quickly as possible.
Follow-up visits to the dietitian are scheduled according to the degree of the patient's nutritional risk. One system originally developed by the Academy of Nutrition and Dietetics and the Los Angeles County Commission on HIV Health Services used the following timelines for HIV patients at nutritional risk:
In addition to an assessment of nutritional needs, RDs also evaluate the patient's living situation and other issues that may affect receiving adequate nutrition.
NAUSEA, VOMITING, AND DIARRHEA. Nausea and vomiting are common symptoms of HIV infection as well as side effects of HAART. They can lead to long-term damage to the esophagus and dental problems as well as weight loss and inability to take needed medications. About 30% of patients develop nausea and vomiting within one to four weeks following infection as part of a condition called acute retroviral syndrome or ARS, which resembles influenza or mononucleosis. Most patients, however, develop nausea, vomiting, and diarrhea later during the course of the disease as side effects of HAART or from opportunistic infections of the gastrointestinal system. Patients with HIV infection are highly susceptible to such diseases as giardiasis, cryptosporidiosis, listeriosis, Campylobacter infections, and Salmonella infections.
Treatment of nausea, vomiting, and diarrhea in patients with HIV infections may require a number of diagnostic tests and imaging studies as well as evaluation of the patient's medications in order to determine the cause(s) of the symptoms.
LIPODYSTROPHY. Lipodystrophy is the medical term for the redistribution of body fat that sometimes occurs in patients with HIV infection as a result of antiretroviral therapy, genetic factors, the length of time a person has been HIV-positive, and the severity of the disease. As of 2018, experts do not completely understand why antiretroviral drugs and other factors have this effect. The patient may notice new deposits of fat at the back of the neck (sometimes called “buffalo humps”) and around the abdomen. Conversely, fat may be lost under the skin of the face, resulting in sunken cheeks, or lost under the skin of the buttocks, arms, or legs. Lipodystrophy is not necessarily associated with weight loss.
WASTING. Wasting refers to rapid unintentional weight loss (usually defined as 5% of body weight over a period of six months) combined with changes in the composition of body tissue. Specifically, the patient is losing lean muscle tissue and replacing it with fat. The patient's outward appearance may not be a reliable guide to wasting, particularly if the patient also has lipodystrophy. Weight loss associated with wasting may result from nausea and vomiting related to opportunistic infections of the digestive tract as well as from reactions to medication.
Nutrition is the first line of defense against wasting. To help the patient maintain weight, nutritionists recommend raising the daily calorie intake from 17–20 calories per 1 lb. (0.45 kg) of body weight (a guideline used for patients whose weight has been stable) to 25 calories per 1 lb. (0.45 kg). Patients with wasting syndrome may require as much as 3500 calories per day to maintain their weight. Nutrient ratios should be 15–20% protein, 50–60% carbohydrates, and 25% fats to protect the body's muscle tissue. Patients who need more calories or protein may benefit from adding supplements such as Ensure or Instant Breakfast to their daily diet. In addition, weight training or other forms of regular exercise help to maintain muscle tissue.
Other treatments for wasting include the use of appetite stimulants to increase food intake and hormonal treatments to build lean muscle tissue, particularly in male patients.
MEDICATION INTERACTIONS. Most medications used in antiretroviral therapy have the potential to cause nausea and vomiting. Some antiretroviral medications should be taken with food to minimize these side effects. Digestive disturbances are the single most common reason given by patients for discontinuing antiretroviral therapy. In some cases, switching to a different combination of drugs helps to relieve nausea, vomiting, or diarrhea.
Paradoxically, antiretroviral medications contribute to obesity in some patients with HIV infection. This development parallels the increase in obesity in the general North American population, and may be related to the increased longevity of patients diagnosed with AIDS. As of 2018, however, the role of ART in weight gain is not well understood.
CHILDREN WITH HIV INFECTION. Children diagnosed with HIV infection require very careful attention to their nutritional status, as recent research indicates that children who are malnourished as well as HIV-positive have a poor prognosis. They are not only more severely ill but less likely to respond to ART.
The function of nutritional education and dietary management in patients with HIV infection and AIDS is to maintain the patient's energy level and ability to carry out normal activities of daily life, lower the risk of opportunistic infections of the digestive system, support the immune system, and minimize the side effects of antiretroviral drugs on the patient's ability to eat and enjoy food.
The benefits of good nutritional care for patients with HIV infection are prolonged survival, improved quality of life, and fewer or less severe side effects from medical treatment.
Food safety is an important concern for patients with HIV infection because their immune systems have difficulty fighting off food- or waterborne disease organisms. While most people can get food poisoning or parasitic infections of the digestive tract if they drink contaminated water or do not prepare food properly, patients with HIV infection can become severely ill due to their compromised immune systems. Foodborne illnesses are also much more difficult to treat in people with AIDS or HIV infection, and may lead to malabsorption syndrome, a condition in which the body cannot absorb and make use of needed nutrients in food. The Food and Drug Administration (FDA) has a brochure with detailed instructions for patients about safety issues in purchasing and preparing foods, particularly when traveling abroad. Basic safeguards include the following:
Patients with special needs include those with limited food budgets or without access to a kitchen for preparing their own food, and nursing mothers with HIV, as there is a risk of transmitting the virus to infants through breast milk.
Patients interested in a vegetarian diet should consult their physician and nutritionist before starting one; raw-food vegetarian diets should be avoided because of the increased risk of contracting foodborne diseases. Detoxification diets and colonics are risky practices for HIV patients and should not be used.
There are no known risks to nutritional management of patients with HIV infection by qualified professionals working with the patient's physicians and nurses. Few risks have been noted in the use of naturopathic dietary supplements or herbal formulas provided that the patient reports the use of alternative therapies to the medical care team and does not use them as substitutes for antiretroviral drugs or other mainstream medications.
Research in the field of nutrition for HIV patients is ongoing and can be expected to produce revised guidelines for dietary management every few years for the foreseeable future. These changes will result as much from mutations in the disease organism as from discoveries of new drugs and other forms of treatment for HIV infection.
Researchers worldwide are paying increased attention to the role of diet and nutrition in improving the quality of life as well as length of survival in people with HIV/AIDS, particularly those living in the developing countries. Of the 132 clinical trials of AIDS-related dietary interventions registered with the National Institutes of Health in early 2018, 72 are being conducted in Africa, Asia, and South America. Interventions that are being studied include vitamins and high-calorie liquid supplements, probiotics, behavior modification through text messaging, and oxandrolone, an anabolic steroid used to promote weight gain. Many of the 60 clinical trials under way in the United States are focused on youth with HIV infection.
See also Detoxification diets ; DHEA ; Dietary supplements ; Fats ; Mediterranean diet ; Metabolism ; Raw foods diet ; Vegetarianism ; Vitamin C ; Whole grains ; Zinc .
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Rebecca J. Frey, PhD