Nutrition Care and Support of HIV Positive Children Living in Limited Resource Settings

1. Nutrition Care and Support of HIV Positive Children Living in Limited Resource Settings Dorcas Lwanga Msc. RD Ellen Piwoz SD SARA Project Academy For Educational Development

2. What is the effect of HIV/AIDS on nutrition ?

3. Effects of HIV/AIDS on Nutrition

4. Effect of HIV on Nutritional Status Stunted growth Linear growth usually first parameter to be negatively affected by HIV disease progression Weight loss Weight gain is also a problem Failure to thrive Infected children born to HIV+ women have early and sustained stunting and are malnourished but not necessarily wasted (Bobat et al 2001)

5. Impact of Nutrition Intervention on HIV disease progression?

6. The impact of home-based management of severe malnutrition using an nutrient-dense ready to use food (RTUF) in HIV-infected and HIV-uninfected children in Malawi

7. Impact of Nutrition Intervention on HIV Disease Progression Vitamin A supplementation every 4-6 months is associated with reduced morbidity in HIV positive children Vitamin A supplementation among HIV positive children < 18 mths resulted in a significant increase in length and after 4 months the increase in length was still significant. The difference noted in length increase remained constant (Villamour et al., 2002) Vitamin A supplementation among HIV positive children resulted in decrease in all cause mortality, and a decrease in diarrhea related deaths (Fawzi WW et al., 1999) In a study in South Africa vitamin A supplementation every 4-6 mths was also associated with decreased morbidity among HIV positive children. The study observed a particularly strong benefit of vitamin A supplementation in decreasing diarrhea among HIV positive children (Coutsoudis et al., 1995)

8. Role of Nutrition Care and Support The Severity of growth failure among HIV-positive children is associated with reduced survival. Studies have shown that clinical outcome of HIV is poorer in individuals with compromised nutrition

9. Role of Nutrition Care and Support Early nutrition intervention can help delay HIV disease progression or death in the HIV positive child Early nutrition intervention can also help: strengthen the immune system, support prevention of opportunistic infections enhance response to therapy

10. Goals of Nutrition Intervention for the HIV- Infected Child Promote optimal growth and development Prevent malnutrition Enhance quality of life by providing adequate energy and nutrients Increase resistance to infections by improving intake

11. Nutrient Requirements for the HIV Infected Child Energy 10% energy increase in asymptomatic HIV infected children to maintain growth If weight loss is present an increase of 50%-100% energy above established requirements for healthy children is recommended Protein Data is insufficient to support increase in protein above normal requirements for health (i.e. 12-15 percent of total energy intake) WHO Technical Advisory Group on Nutrition and HIV/AIDS, 2003 forthcoming

12. Nutrient Requirements for the HIV Infected Child Micronutrients Periodic (every 4-6 months) supplementation with Vitamin A for children 6-59 months 6-12 months – 100,000 IU > 12 months – 200,000 IU No data at present on the efficacy of individual micronutrient supplements other than vitamin A in HIV infected children. WHO Technical Advisory Group on Nutrition and HIV/AIDS, 2003 forthcoming

13. Recommendations for nutrition care and support of the HIV+ child Provide growth monitoring and promotion HIV-infected children are at high risk for growth failure body weight, height should be monitored regularly (at least monthly) arm circumference and triceps skin fold should be monitored periodically if possible Improve nutritional status Improve diets and provide adequate overall nutrition HIV infected children should be given multivitamins where available, prophylactic vitamin A supplements and immunized according to local immunization policies manage dietary problems such as diarrhea, anorexia, vomiting source: Lepage et al, 1998

14. Recommendations for nutrition care and support of the HIV+ child Improve diet to meet needs for growth and development The child’s diet should be reviewed at every well-child and sick child health visit. Conditions affecting appetite and food intake should be discussed and treated as appropriate. Advice on how to improve the diet, taking into consideration the child’s age, local resources and the family circumstances, should be given. Promote good hygiene, and food and water safety to avoid pathogenic contamination e.g. diarrhea follow the same safe and hygienic practices as those provided for adults source: Lepage et al, 1998

15. Recommendations for nutrition care and support of the HIV+ child Promptly treat secondary infections secondary infections such as tuberculosis, oral thrush, persistent diarrhea, and pneumonia should be promptly treated. The nutritional impact of these infections should be minimized by maintaining food and fluid intake to the degree possible Provide treatment for severe malnutrition Many HIV infected children are likely to become severely malnourished. Local guidelines for the management of severe should be followed. Enteral and parenteral nutrition should be considered, when available, if the child is unable to eat source: Lepage et al, 1998

16. Recommendations for nutrition care and support of the HIV+ child Provide antiretroviral medications where available and affordable In a US based study, use of Protease Inhibitors in HIV infected children not only decreased viral load but also had a positive effect on growth parameters including weight, weight for height and muscle mass (Miller et al., 2001)

17. Recommendations for feeding Children with HIV Solid foods should be introduced gradually to match the age and developmental characteristics of the child Care givers should feed children a variety of locally available fruits and vegetables and animal products if available to increase intake of essential vitamins and minerals Feeding should be done patiently and persistently with supervision and love, especially for the HIV infected child who may be frequently ill and suffering from fever, mouth sores and decreased appetite. Provide a daily multivitamin supplement, if available, to help prevent nutrient deficiencies,

18. Infant Feeding and HIV

19. WHO Recommendations on Infant Feeding(WHO 2001) “When replacement feeding is acceptable, feasible, affordable, sustainable, and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended. Otherwise, exclusive breastfeeding is recommended during the first six months of life. To minimize HIV transmission risk, breastfeeding should be discontinued as soon as feasible, taking into account local circumstances, the individual woman’s situation and the risks of replacement feeding ( including infections other than HIV and malnutrition.)”

20. Nutrition Intervention and AntiRetroviral medications in the Care and Support of HIV Infected Children

21. Nutrition and ARV Therapy The common side effects of medications affect food intake and hence nutritional status Nausea, vomiting, diarrhea, anorexia, altered taste Counseling and education on timing of medications and meals and snacks, food composition is important For drug efficacy Maintenance of nutritional status Nutritional management of side effects is crucial Maintain good nutritional status Increase tolerance to drugs

22. Issues & Challenges

23. Issues/Challenges Nutrition improvement is likely to have its greatest impact early on, but for most infants and children the HIV status is not known until they have advanced disease with malnutrition Need greater availability, access to VCT Improve quality of care, treatment Access to food is one of the main challenges faced by many poor households in sub-Saharan Africa Poor quality complementary foods

24. Issues/Challenges Limited research on traditional therapies interactions with ARV as they become available Need research on ARV interactions and traditional therapies Management of metabolic complications associated with use of ARV’s over long term period in children Glucose and lipid metabolism, bone metabolism

25. Issues and Challenges We do not know what the effect of HIV infection is on micronutrient requirements among children infected protein and fat requirements for the HIV infected child Time and availability of staff and training lack of human resource capacity Keeping parents alive Provide access to affordable ARV therapy for infected parents Improve food security constraints

26. Thank you As we continue in our work in the care and support of HIV infected children let us reflect and discuss What are the most important care and support practices to consider when caring for an HIV infected infant/child?Thank you As we continue in our work in the care and support of HIV infected children let us reflect and discuss What are the most important care and support practices to consider when caring for an HIV infected infant/child?