HIV Infection and Nutrition

HIV in Bangladesh-Current Scenario; Nutrition and HIV: Science vs Hyperbole- Where Is the Intersection?; Management of Severe Malnutrition in HIV-infected Children: Recent Review of Current Evidence; Nutrition and HIV Programming Framework-Evidence and Policy Implications

Special Session on HIV Infection and Nutrition from the 8th Commonwealth Congress on Diarrhoea and Malnutrition

- HIV in Bangladesh__Current Scenario
- Nutrition and HIV: Science vs Hyperbole__Where Is the Intersection?
- Management of Severe Malnutrition in HIV-infected Children: Recent Review of Current Evidence
- Nutrition and HIV Programming Framework__Evidence and Policy Implications

Title of paper: HIV in Bangladesh__Current Scenario

Authors: Tasnim Azim (1) ([email protected]), Mahmudur Rahman (2), M. Shah Alam (1), Charles P. Larson (1), Sharful Islam Khan (1), Md. Elahi Chowdhury (1), R. Khanam (1), Ezaz I. Chowdhury (1), Imtiaz A. Chowdhury (2), Motiur Rahman (1), Masud Reza (1), Md. A. Salim (3), and A.S.M. Matiur Rahman (3)

(1)ICDDR,B: Centre for Health and Population Research, GPO Box 128, Dhaka 1000, Bangladesh
(2)Institute of Epidemiology, Disease Control and Research, Mohakhali, Dhaka 1212, Bangladesh, and
(3)NASP, Directorate General of Health Services, New DOHS, Dhaka, Bangladesh

Since the second-generation surveillance was initiated in Bangladesh in 1998 among population groups most at risk of an epidemic, the total HIV prevalence has remained below 1%. However, the HIV epidemic in Bangladesh is evolving rapidly and, in one city, in injecting drug users (IDUs), the HIV prevalence increased from 1.4% to 4.9% from 1999 to 2004. In one neighbourhood in that city, approximately 8% of IDUs were HIV-infected.

Simultaneously, recent Behavioural Surveillance Survey (BSS) data indicate an increase in risk behaviours, such as sharing of injecting equipment and a decline in consistent condom use in sexual encounters between IDUs and female sex workers. A prospective cohort study among female IDUs has shown that most women are also sex workers, and a sub-set have both commercial and non-commercial sex partners and share needles/syringes with their non-commercial sex partners. All sources of data indicate that the IDU population is well-integrated into the surrounding urban community, socially and sexually, thus raising grave concern about the spread of HIV infection.

Female sex workers have high rates of active syphilis and other sexually transmitted infections but very low rates of HIV infection. Casual female sex workers (i.e. those who sold sex part-time) were sampled in surveillance from 3 border cities. The sex workers in the 2 Northwest border cities commonly reported crossing over the border to India and selling sex while across the border. Sex workers were sampled from Southeast-H1 bordering Myanmar, but the proportions reporting crossing over to Myanmar and selling sex were small. In this city, although no HIV was detected, active syphilis rates were high (10%). Hotel-based sex workers were comparatively younger and had the highest number of clients among all female sex worker groups. Consistent condom use by female sex workers remains low in all groups. From passive case reporting through Voluntary Counselling and Testing centres, the highest rates of HIV infection have been found in migrants returning from jobs abroad and in their families.

Migrants who live away from their families for prolonged periods also report higher rates of extramarital sex and commercial sex. As the HIV rates are rising steadily, it will soon be too late to prevent a large-scale epidemic if intervention programmes are not scaled up and adapted to the needs of the communities that they serve. Stigma continues to remain a major barrier to working with marginalized population groups.

Title of paper: Nutrition and HIV: Science vs Hyperbole__Where Is the Intersection?

Author: Nigel Rollins ([email protected])
University of KwaZulu-Natal, South Africa and WHO Technical Advisory Group on Nutrition and HIV

The HIV pandemic in sub-Saharan Africa has been imposed on populations already afflicted with poverty, poor food security, and chronic malnutrition. From the earliest clinical descriptions and reports, the impact of HIV on the nutritional status of infected adults and children has been obvious--Slim disease. Despite this, there is a remarkable paucity of clinical data bringing understanding to the metabolic processes that result in the all too common anorexia and wasting.

There are even less data describing the benefit of nutritional interventions, macronutrient, and micronutrient in alleviating symptoms and improving the quality and duration of life of infected adults and children. The belated arrival of anti-retroviral drugs, while welcome, adds to the list of unknowns, such as whether the pharmacokinetics of these drugs differ in children who are severely malnourished compared to those who are less under-nourished. In response, the World Health Organization commissioned a technical review on the nutritional requirements of HIV-infected adults and children.

Some of the key findings include:
o Energy needs increase by about 10% in adults and children from the time of infection
o During and after severe illnesses, these needs might increase by a further 20-30%. In children, this may be up to 150%
o There is no evidence for increased protein requirements other than in a balanced diet, i.e. 12-15% of the total energy intake
o Anorexia and poor dietary intake are important causes of weight loss
o Improving the diet alone, though, may not result in weight recovery and improvement in clinical status
o To obtain the maximum benefit of anti-retroviral drugs, adequate and appropriate nutritional intake is necessary

The programmatic implications of these findings are complex and are made more difficult by issues of equity, ensuring access to adequate and appropriate food, the commercial and exploitive interests of entrepreneurs, and health systems that in the past have failed to prevent and manage chronic malnutrition in children.

Title of paper: Management of Severe Malnutrition in HIV-infected Children: Recent Review of Current Evidence

Author: Sultana Khanum ([email protected] )
Department of Nutrition for Health and Development, World Health Organization, Avenue Appia,
1211 CH, Geneva 27, Switzerland

Malnutrition contributes to 53% of deaths of children, aged less than 5 years, in developing countries. Severely-malnourished children often comprise the majority of inpatient paediatric deaths. This is because a higher proportion of them die compared to other paediatric admissions, and this primarily stems from poor understanding of the complexity of physiological changes and of correct case-management among doctors and nurses. Typically, 25-30% of children with severe malnutrition die during hospital treatment; the rate is even higher (50-70%) in African hospitals. Most of these deaths can be avoided by following treatment guidelines. The World Health Organization (WHO), together with international experts, has developed guidelines for treating severe malnutrition and a training course for doctors and nurses. Where the guidelines have been implemented appropriately, mortality has been reduced by at least half. In September 2004, the WHO held a consultation to consider if changes to the WHO malnutrition guidelines may be required as a result of new evidence.

The consultation concluded that only limited peer-reviewed new research for the period under review (1998-2004) is done, in which severely-malnourished children had been studied. During this period, however, substantial advances in knowledge about HIV/AIDS have occurred, and there is now increased opportunity for HIV-testing and anti-retroviral therapy. With regard to HIV/AIDS, changes in the guidelines were, therefore, recommended in relation to treatment of pneumonia and provision of prophylactic co-trimoxazole for severely-malnourished HIV-positive children. Knowledge gaps were identified, particularly in relation to feeding infants aged less than 6 months with severe malnutrition and to the effectiveness and pharmaco dynamics of anti-retroviral therapy in severely-malnourished children who are HIV-positive.

To guide policy regarding optimal dietary management of very young severely-malnourished infants, there is an urgent need for observational studies of alternative formulations. Also, in the case of HIV-positive infants where definitive diagnostic virological testing of HIV is not available, research is needed to identify signs that are predictive of HIV, indications for treatment with antiretroviral and their pharmacokinetics and safety of different anti-retroviral drugs and regimens in severely-malnourished infants and children.


Title of paper: Nutrition and HIV Programming Framework__Evidence and Policy Implications

S.M. Moazzem Hossain (1) ([email protected]), Arjan de Wght (2), and Saba Mebrahtu (30
(1) Nutrition Section, Programme Division, United Nations Children’s Fund, 3 UN Plaza, 44 ST E,
Manhattan, NY 10017, USA, (2) EAPRO, United Nations Children’s Fund, Bangkok, Thailand, and
(3) ESARO, United Nations Children’s Fund, Nairobi, Kenya

Background: The world has over 40 million people living with HIV/AIDS. HIV/AIDS negatively impacts on a person's nutrition status in different ways. During the last few years, there have been several major international meetings establishing goals for children that relate to nutrition and HIV/AIDS.

Objective: The objective of developing a programming framework is to set priority action for the high HIV-burden countries and strengthen capacity of the major stakeholders to reduce food insecurities among families and individuals infected/affected by HIV and improve their nutritional status.

Methodology: Systematic reviews commissioned by the World Health Organization (WHO), international consultation meeting, and small working groups to assess programme and policy implications were analyzed.

Results: Evidence suggests that energy requirements for people living with HIV/AIDS (PLWHA) are increased by 10% for asymptomatic patients, 20-30% for symptomatic patients, and 50-100% for children with weight loss but data are insufficient to suggest increased protein requirement in PLWHA. Optimal nutrition of HIV+ mothers during pregnancy/lactation increases weight gain and improves pregnancy and birth outcomes. It was also found that long-term use of ART was associated with metabolic complications, but the value of ART outweighs risks. There is a need to look at interactions between nutrition and ARVs in chronically-malnourished populations. There is increased evidence that nutrition support during severe infection in people living with HIV/AIDS alters severity and outcome of infections and rate of recovery. The effects of good nutrition on HIV/AIDS are more pronounced if nutrition is promoted from the early stages of the disease. However, most infected people are not aware of their status until opportunistic infections begin to set in. Therefore, there is a need to promote nutrition in the general population and provide nutrition care and support as part of a comprehensive package for individuals and families affected by HIV/AIDS.

Conclusion: The action that is urgently required for each component is to conduct a situation assessment and analysis, set priority action and advocacy for resource allocation, develop national policies/strategies/protocols, support women and children affected by HIV through nutrition assessment, dietary guidance, community-based care and support, food interventions, micronutrients supplementation, and finally establish a monitoring and evaluation mechanism,
conduct operational studies, and document experiences.

Acknowledgements: Systematic reviews for evidences were commissioned by the WHO Technical Advisory Group, while the international consultation was organized by WHO in collaboration with Ministry of Health, South Africa, United Nations Chidlren’s Fund, and other partners.