Care of Women with HIV Living in Limited-Resource Settings HIV and Nutrition: Care and Support

1. Care of Women with HIV Living in Limited-Resource Settings HIV and Nutrition: Care and Support Dorcas Lwanga, MSc, RD Nutrition Advisor Academy for Educational Development

2. Objectives • Review goals and components of nutrition care and support • Discuss nutrition recommendations for the symptoms associated with each stage of HIV disease • Provide information on how to manage nutrition-related symptoms of HIV

3. Role of Nutrition Care and Support • Studies have shown that the clinical outcome of HIV is poorer in individuals with compromised nutrition • Improving nutrition can help prevent weight loss, strengthen the immune system and delay HIV disease progression. • Nutrition care should be part of a comprehensive program that helps the HIV-infected individual and her family

4. Goals of Nutrition Care and Support • Improve nutritional status • Maintain weight, prevent weight loss • Preserve muscle mass • Ensure adequate nutrient intake • Improve eating habits and diet • Replenish stores of essential nutrients • Prevent food-borne illnesses • Enhance quality of life • Treat opportunistic infections • Manage symptoms affecting food intake • Provide palliative care

5. Components of Nutritional Care and Support • Nutrition assessment • Weight • Mid-arm circumference • Nutrition education and counseling • Adequate diet • Proper food handling and safety • Hygiene • Water • Sanitation

6. Components of Nutritional Care and Support continued • Nutrition supplementation • Food • Vitamin and mineral supplements • Food and nutrition support for families • Food-for-work • Community kitchens • Home-based care • Food baskets • Home-delivered, ready to eat meals

7. Stages of HIV Disease and Nutrition • Specific nutrition recommendations vary according to the underlying nutritional status and extent of HIV disease progression: • Early - no symptoms, stable weight • Middle - weight loss • Late - symptomatic AIDS

8. Nutrition Care and Support Priorities by Stage of Disease • Early stage – “stay healthy” • Build stores of essential nutrients • Maintain weight and lean body mass • Ensure understanding of food and water safety • Middle stage – “minimize consequences” • Maintain dietary intake during acute illness • Increase nutrient intake for recovery/weight gain • Continue physical activity • Late stage – “provide comfort” • Treat opportunistic infections • Modify diet according to symptoms • Encourage eating and physical activity

9. Recommendations for Nutrition Care and Support: Early Stage • Identify locally available and acceptable foods • Promote a diet adequate in energy, protein and other essential nutrients • Energy requirements are increased by 10-15% • Protein requirements are increased ~ 50% • Requirements for vitamins and minerals used by the immune system are also increased • Maintain physical activity • Weight-bearing exercise builds lean body mass • Exercise stimulates appetite • Prevent food-borne illnesses through safe food handling practices

10. Recommendations for Safe Food Handling Practices • Wash hands before preparing and eating food, after using the toilet or changing nappies or diapers • Wash all food preparation surfaces, utensils and dishes • Wash all fruit and vegetables before eating, cooking or serving • Avoid letting raw food come in contact with cooked food • Cook food thoroughly • Serve food immediately after preparation

11. Recommendations For Safe Food Handling Practices continued • Keep food covered and away from insects, rodents and other animals • Do not store cooked food • Always use boiled or bottled water for drinking, cooking, and cleaning dishes and utensils • Never use bottles with teats for feeding infants. Use a cup instead

12. Recommendations for Nutrition Care and Support: Middle Stage • Maintain intake during periods of acute illness and depressed appetite • Increase nutrition intake to promote weight and muscle mass gain, and nutritional recovery • Make every bite count • Daily vitamin-mineral supplements • Continue physical activity as able

13. Recommendations for Nutrition Care and Support: Middle Stage continued • Manage the symptoms that affect food intake • Loss of appetite • Nausea • Mouth sores • Diarrhea • Seek medical attention immediately • High fever or fever for more than 3 days • Persistent diarrhea • Other symptoms of infection • Avoid unhealthy behaviors • Alcohol, smoking and drug use • Unsafe sexual practices

14. Recommendations for Nutrition Care and Support: Late Stage • Treat all infections that affect appetite, ability to eat and retention of nutrients • Consider the food and nutritional interactions with medicines • Consider the side effects of medications that affect intake • Maintain intake during periods of acute illness and depressed appetite • Modify diet according to symptoms • Encourage physical activity • Provide psychological and emotional support

15. Recommendations for Symptom-Based Nutrition Care and Support

16. Recommendations for Symptom-based Nutrition Care and Support continued

17. Recommendations for Symptom-Based Nutrition Care and Support continued If diarrhea is severe, food may be withheld for 24 hrs or restricted to only clear fluids, such as, soups, tea or soft foods (mashed fruit, potatoes, white rice, porridge)

18. Recommendations for Symptom-Based Nutrition Care and Support continued

19. Recommendations for Symptom-Based Nutrition Care and Support continued

20. Source of Various Vitamins and Minerals

21. Source of Various Vitamins and Minerals continued

22. Some Recommended Foods

23. Recommendations on Foods to Avoid The aim of good nutrition care and support is to ensure adequate intake and to maintain weight and lean body mass. Therefore, other than the following, no foods should be eliminated unnecessarily. • Raw eggs • Foods that have not been thoroughly cooked, especially meats and chicken • Water that is not boiled or juices that are made from water that is not boiled • Alcohol and coffee • “Junk” foods such as chips, biscuits and sweets with little nutritional value • Foods that aggravate symptoms related to diarrhea, nausea/vomiting, bloating, loss of appetite, and mouth sores

24. Nutrition and Medication Medications used to treat HIV opportunistic infections may result in negative drug-nutrient interactions or cause side effects. • Vitamin B6 supplementation should be administered with isoniazid therapy for tuberculosis to avoid Vitamin B6 deficiency • Iron and zinc-containing supplements should not be taken with ciproflaxacin • Sulfadoxine and Pyrimethamine (Fansidar) used for treatment of malaria is not recommended if the patient is folate deficient. • Some antiretroviral drugs have: • Dietary requirements • Side effects with nutritional consequences • An effect on red blood cell production, increasing risk of anemia (e.g. Zidovudine (AZT)).

25. Summary • Maintaining adequate nutrition may be one of the most important things a newly infected person can do to prolong well-being. • Good nutrition and healthy lifestyle can: • Preserve health • Improve quality of life • Prolong independence • Delay disease progression • Prevention of food and water-borne infections reduces the risk of diarrhea, a common cause of weight loss, malnutrition and HIV disease progression in people living with HIV and AIDS.

26. Summary continued • Managing common symptoms related to HIV/AIDS can minimize their impact on nutritional status. • Continuing physical activity and exercise, as appropriate, increases energy, stimulates appetite and preserves and builds lean body mass. • Providing psychosocial and emotional support as part of nutrition care at all stages of HIV disease can help to improve quality of life. • Nutritional care and support should be part of a comprehensive program that deals with the needs of the patient and her family.