Noraishah Mohamed NorDept Nutrition ScIIUM
Definitions HIV  Human Immunodeficiency Virus – a retrovirus   that targets the CD4 T helper immune cells AIDS  Acquir...
Introduction                           Global          Sub-Saharan Africa  People Living          40.3 million          25...
Statistic in M’sia                 HIV INFECTION                     AIDS CASES                     AIDS DEATHYEAR        ...
HIV/AIDS Classification
HIV transmission and riskfactors   Transmission of HIV     Fluids commonly associated with transmission of      HIV     ...
○ Exposure to blood and blood  products   IV drug users   Improperly screened blood and    blood products○ Congenital ex...
Acute HIV infection   Due to initial infection and dissemination through out the    body and occurs 1-4 weeks after expos...
Seroconversion   Body takes a few days to weeks to recognize a    foreign substance like a virus   Once substance is rec...
Asymptomatic HIV infection   For several years after one is HIV antibody test    positive, People with HIV infection feel...
   Virus in the blood remain low and constant    for many years   Eventually the body can’t quite keep up and    with ti...
Symptomatic HIV disease   Early symptomatic HIV disease     Declining CD4     Increasing virus in blood     Symptoms i...
Progression to AIDS   Typical progressors: 8-10 years asymptomatic    HIV before developing AIDS     Fall in viremia fol...
Factors influencing the timecourse to progression to AIDS Acute infection is symptomatic Viral strain Higher viral “set...
Clinical staging based onNatural history   WHO staging into IV stages:     Stage I: Asymptomatic and has normal activity...
Diagnosis of HIV/AIDS   Screening Tests licensed by the FDA     Test serum or plasma with high sensitivity to HIV      t...
Treatment   Antiretroviral Therapies (ART)     Nucleoside reverse transcriptase inhibitors     Nonnucleoside reverse tr...
HIV/AIDS RelatedClinical Complications   Neuropathy     Antiretroviral (ARV) therapies   Dementia     HIV infection, o...
   Hepatic Disorders     Opportunistic infection, anti-HIV treatment toxicity   Anemias     Chronic HIV, hormonal alte...
Role ofDietitian in HIV/AIDS Care Monitor caloric intake Document nutritional adequacy Recommend methods for increasing...
Nutrition Complications Malnutrition   Malabsorption   Hypermetabolism   Diminished intake    ○   Dysphagia – mouth le...
 Malnutrition       leads to:       Malabsorption       Complications with treatment regimens       Decreased immune f...
   Malabsorption:     Most common – fat malabsorption     Associated with:      ○ Starvation-style malnutrition      ○ ...
Nutrition - Treatment Interaction   Efficacy of treatment dependent on    nutritional status maintenance and vice    vers...
Altered immune function   Leads to:     Hypermetabolism     Opportunistic infections      ○ Candidiasis      ○ Cytomega...
Organ Dysfunction Liver Lungs Pancreas Heart Small intestine
Micronutrient Deficiencies   Caused by decreased absorption and    metabolism of nutrients and accelerated    turnover   ...
Weight Loss – AIDSWasting   AIDS Wasting: “involuntary loss of greater than    10% of baseline body weight, accompanied b...
   Caused by:     Reduced food intake     Malabsorption     Abnormal nutrient utilization and metabolism     Oxidativ...
   More important than weight loss is body    composition alterations     Decreased Body Cell Mass (BCM)– metabolically ...
HAART in AIDS Wasting   Body composition changes despite weight    maintenance     Lean tissue wasting     Lipodystroph...
Nutrition Intervention Goals:     Preserve body cell mass     Provide adequate amounts of all nutrients for      proper...
Nutrition Assessment Should   take place at diagnosis of  HIV Patient-Generated Subjective  Global Assessment (PG-SGA) ...
Measuring BodyComposition   Anthroprometrics     Tricep skinfold     Midarm Circumference   Bioelectrical impedance an...
Biochemical Assessment   Selected biochemical measures for HIV     Immunologic      ○ CD4 count      ○ Viral Load     H...
   Organ Function        Cardiovascular     AST                     Total Cholesterol     ALT                     HD...
Energy & Protein Needs   Energy – based on need to maintain weight     Harris-Benedict Formula X 1.3 (wt maintenance )  ...
Micronutrient Needs   Dietary Reference Intakes     Vitamin A – 700-900 μg/day      ○ Immune function     Vitamin E – 1...
Fluids & Electrolytes Fluids : 30 -35 ml/kg (8 -12 glass) Replacement of electrolytes (sodium,  potassium, and chloride)...
Symptom Management  Nausea and Vomiting  ○ Replace fluids and electrolytes  ○ Bland, odorless foods  ○ Beverages between ...
 Anorexia ○ Eat favorite foods often in relaxed settings ○ Add flavors and an array of colors ○ Keep snacks handy ○ Appet...
Nutrient Supplementation   Specific micronutrient supplementation has shown    various results, and general multivitamin ...
   High energy, high-protein oral    supplement     Prospective intervention trial (N=17) Boston, MA     Take one high-...
   Glutamine (GLN) -Antioxidant    Supplementation     Increase body cell mass in AIDS patients     with weight loss    ...
Conclusion   HIV/AIDS is a complicated disease and requires    critical assessment by a multidisciplinary team   Mainten...
Questions?       ? ??    ? ??    ?
“Do What you Can  with what you Have     Where you Are !”
Assignment…. Nutrition & Bone health Nutrition for oral & dental health MNT for psychiatric disorder
mnt-for-human-immunodeficiency-virus-hiv
mnt-for-human-immunodeficiency-virus-hiv
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  • HIV (pink) enters the body and binds to dendritic cells (orange), which carry the virus to CD4+ T cells. Infected CD4+ T cells home to lymphoid tissue, where the infection is established. Virus replication accelerates, and massive viremia leads to the wide dissemination of virus throughout the body's lymphoid tissue. An HIV-specific immune response occurs and virus is trapped on the follicular dendritic cells of germinal centers in the lymphoid tissue. At this point, chronic, persistent infection is established despite an immunological response to the virus. Immune activation is an important driver of HIV replication and is mediated by the secretion of various cytokines and by aberrant cell signaling caused by interaction of the viral envelope with cellular receptors. Because there is usually only partial immunological control of virus replication, continual and accelerated production of virus ensues. This is associated with a rapid turnover of CD4+ T cells. Ultimately, lymphocyte depletion occurs, along with destruction of the architecture of lymphoid tissue
  • Contagious - capable of being transmitted by infection
  • The development of detectable antibodies in the blooddirected against an infectious agent. It normally takes some time for antibodies to develop after the initial exposure to the agent.
  • mnt-for-human-immunodeficiency-virus-hiv

    1. 1. Noraishah Mohamed NorDept Nutrition ScIIUM
    2. 2. Definitions HIV  Human Immunodeficiency Virus – a retrovirus that targets the CD4 T helper immune cells AIDS  Acquired Immunodeficiency Syndrome – the final stage of HIV infection  The result of infection with HIV is a inability of the body to defend itself against other invaders leading to opportunistic infections
    3. 3. Introduction Global Sub-Saharan Africa People Living 40.3 million 25.8 million With HIV/ AIDS *57% women (2005)New HIV Infections 4.9 million 3.2 million (2005) (70%) (14,000 people infected everyday)AIDS Related Deaths 3.1 million 2.4 million (2005)
    4. 4. Statistic in M’sia HIV INFECTION AIDS CASES AIDS DEATHYEAR Male Female TOTAL Male Female TOTAL Male Female TOTAL1986 3 0 3 1 0 1 1 0 11987 2 0 2 0 0 0 0 0 01988 7 2 9 2 0 2 2 0 21989 197 3 200 2 0 2 1 0 11990 769 9 778 18 0 18 10 0 101991 1741 53 1794 58 2 60 10 9 191992 2443 69 2512 70 3 73 44 2 461993 2441 66 2507 64 7 71 50 5 551994 3289 104 3393 98 7 105 74 6 801995 4037 161 4198 218 15 233 150 15 1651996 4406 191 4597 327 20 347 259 12 2711997 3727 197 3924 538 30 568 449 24 4731998 4327 297 4624 818 57 875 655 34 6891999 4312 380 4692 1114 86 1200 824 50 8742000 4626 481 5107 1071 97 1168 825 57 8822001 5472 466 5938 1188 114 1302 900 75 9752002 6349 629 6978 1068 125 1193 823 64 8872003 6083 673 6754 939 137 1076 633 67 7002004 5731 696 6427 1002 146 1148 951 114 10652005 5383 737 6120 1044 177 1221 882 102 9842006 4955 875 5830 1620 222 1842 896 80 9762007 3804 745 4549 937 193 1130 1048 131 11792008 2988 704 3692 795 146 941 786 114 900TOTAL 77,092 7,538 84,630 12,992 1,548 14,576 10,273 961 11,234
    5. 5. HIV/AIDS Classification
    6. 6. HIV transmission and riskfactors Transmission of HIV  Fluids commonly associated with transmission of HIV ○ Vaginal fluids ○ Semen ○ Blood and blood components ○ Breast milk  Behavioral risk factors ○ Sexual intercourse whether vaginal, anal or oral  Number of sexual partners  Intercourse with HIV infected  Unprotected sex( lack of use of barrier precautions)  Presence of STI (sexually transmitted infection)  Influence of alcohol and other substances that impairs decision making
    7. 7. ○ Exposure to blood and blood products  IV drug users  Improperly screened blood and blood products○ Congenital exposure  Exposure in pregnancy, labour and breast feeding
    8. 8. Acute HIV infection Due to initial infection and dissemination through out the body and occurs 1-4 weeks after exposure Common symptoms; Headache, fever, rash, sorethroat, tiredness, muscle pain, enlarged lymph glands.  Usually <14 days but may be weeks or months.  Non specific and could easily pass for common viral infections Others; Nausea, vomiting, diarrhea, weight loss and acute psychological problems like irritability and confusion Amount of virus in blood and genital secretions is so high. This is when most people are contagious. Occurs in 70 % of individuals
    9. 9. Seroconversion Body takes a few days to weeks to recognize a foreign substance like a virus Once substance is recognized, body produces antibodies that attack it For HIV, 6-12 weeks after the virus has entered the body, antibodies are in sufficient quantities to be detected by the usual tests >95% people have positive tests by 3 months while >99% of people have positive tests by 6 months In most infections once antibodies and other protective cells appear, organisms are eliminated but not so with HIV
    10. 10. Asymptomatic HIV infection For several years after one is HIV antibody test positive, People with HIV infection feel good. No clinical signs or symptoms Person unaware of HIV infection unless tested About 70-80% of people who are presently infected with HIV are in this asymptomatic phase HIV continues reproducing every day making new viruses and destroying body’s defenses. The body continues to produce new CD4s to offset the loss
    11. 11.  Virus in the blood remain low and constant for many years Eventually the body can’t quite keep up and with time progressive depletion of CD4 occur The duration of this stage depends on how effective the body’s defenses were able to control the initial infection and therefore the amount of virus in blood(8-10 years) Period is longer the earlier the age at time of initial infection
    12. 12. Symptomatic HIV disease Early symptomatic HIV disease  Declining CD4  Increasing virus in blood  Symptoms include Fever, unexplained weight loss, recurrent diarrhea, headache, tiredness and skin problems Late symptomatic HIV disease (AIDS)  Defense system is sufficiently compromised, the patient is unable to control other infections leading to opportunistic infections and cancers  Without treatment the patient on average dies within 1-3 years  Signs and symptoms typically parallels laboratory testing of CD4 counts  Individuals could have very low CD4 without symptoms  Risk of death from HIV infection with CD4 counts above 200 is low
    13. 13. Progression to AIDS Typical progressors: 8-10 years asymptomatic HIV before developing AIDS  Fall in viremia following acute infection Rapid progressors  Develop AIDS in 2-3 years following initial infection  High viral load during acute infection and levels do not fall to those of typical progressors Non progressors “long survivors”  Relatively stable immune function for more that 10 years. Stable CD4  Low viral burden
    14. 14. Factors influencing the timecourse to progression to AIDS Acute infection is symptomatic Viral strain Higher viral “set point” Older age at sero conversion Opportunistic infection or neoplasm present In Mother to child, signs of infection at <3months
    15. 15. Clinical staging based onNatural history WHO staging into IV stages:  Stage I: Asymptomatic and has normal activity  Stage II: Symptomatic with weight loss, minor skin problems, Herpes zooster  Stage III: unexplained chronic diarrhea, unexplained prolonged fever, PTB; Usually bed ridden < 50% of the day during last month  Stage IV: Opportunistic infection eg PCP, Cryptococcal meningitis, Toxoplasma infection of brain etc. Usually bed ridden > 50% of the day during last month
    16. 16. Diagnosis of HIV/AIDS Screening Tests licensed by the FDA  Test serum or plasma with high sensitivity to HIV type 1 (HIV-1) antibodies ○ Enzyme-Linked Immunoabsorbent Assay (ELISA)  Confirmatory test ○ ELISA, Enzyme Immunoassay (EIA), Western blot, modified Western blot, indirect immunoflourescent antibody assay (FIA), and line immunoassay (LIA)  Combination ELISA testing ○ Both antigen and antibodies ○ Earlier diagnosis
    17. 17. Treatment Antiretroviral Therapies (ART)  Nucleoside reverse transcriptase inhibitors  Nonnucleoside reverse transcriptase inhibitors  Protease inhibitors  Fusion inhibitors Highly active retroviral therapy (HAART)  Introduced in 1996  Combinations of ART medications (3 or more) Aimed at interrupting viral life cycle and decreasing viral load  Goal: < 50 copies/mL Only prolong life and suppress symptoms, no cure currently exists
    18. 18. HIV/AIDS RelatedClinical Complications Neuropathy  Antiretroviral (ARV) therapies Dementia  HIV infection, other infections, nutrient deficiencies Pulmonary disorders  HIV infection – low CD4 count Cardiac Manifestations  Inflammation process, infections, ARV medication
    19. 19.  Hepatic Disorders  Opportunistic infection, anti-HIV treatment toxicity Anemias  Chronic HIV, hormonal alterations, infections, ARV medications Renal Failure  ARV medications, infection ○ HIV-associated nephropathy, tubular necrosis, nephrolithiasis (kidney stones)
    20. 20. Role ofDietitian in HIV/AIDS Care Monitor caloric intake Document nutritional adequacy Recommend methods for increasing intake Education on proper diet and food safety Monitor nutrition abnormalities from treatment Make recommendations to the rest of the team in relation to nutrition
    21. 21. Nutrition Complications Malnutrition  Malabsorption  Hypermetabolism  Diminished intake ○ Dysphagia – mouth lesions ○ Odynophagia – lesions to esophagus ○ Dygeusia ○ Diarrhea – intestinal dysfunction due to pathogen ○ Anorexia – neuropsychiatric, endocrinologic, or gastrointestinal ○ Early satiety ○ Nausea and vomiting – side effect of medication ○ Fever – opportunistic infections ○ Fatigue – lean body mass depletion ○ Apathy ○ Depression
    22. 22.  Malnutrition leads to:  Malabsorption  Complications with treatment regimens  Decreased immune function  Organ dysfunction  Micronutrient deficiencies  Weight Loss – AIDS Wasting A well-nourished HIV positive person with a controlled viral load is more likely to be able to withstand the effects of HIV infection
    23. 23.  Malabsorption:  Most common – fat malabsorption  Associated with: ○ Starvation-style malnutrition ○ Villous atrophy ○ Intestinal cell maturation defects ○ Increased gut permeability ○ Autonomic neuropathy ○ Gastrointestinal pathogens
    24. 24. Nutrition - Treatment Interaction Efficacy of treatment dependent on nutritional status maintenance and vice versa  Low nutrition status  drug efficacy: ○ Reduces drug absorption ○ Reduces activation and elimination of most drugs  Treatment  nutrition status ○ Reduce muscular protein synthesis ○ Diarrhea ○ Nausea/Vomiting ○ Appetite Loss
    25. 25. Altered immune function Leads to:  Hypermetabolism  Opportunistic infections ○ Candidiasis ○ Cytomegalovirus ○ Hepatitis C ○ Herpes Simplex ○ Mycobacterium Avium Complex (MAC) ○ P. Jeroveci (PCP) ○ Many more
    26. 26. Organ Dysfunction Liver Lungs Pancreas Heart Small intestine
    27. 27. Micronutrient Deficiencies Caused by decreased absorption and metabolism of nutrients and accelerated turnover  Most common:  Others documented: ○ Vitamin A  Vitamin B6 ○ Vitamin E  Vitamin D ○ Vitamin B12  Folate ○ Selenium  Carotenoids ○ Zinc  Riboflavin  Copper
    28. 28. Weight Loss – AIDSWasting AIDS Wasting: “involuntary loss of greater than 10% of baseline body weight, accompanied by either chronic diarrhea (at least two loose stools per day for greater than 30 days) or chronic weakness and fever for 30 days or longer In the absence of concurrent illness or conditions” – CDC 1987  Recommended revisions: ○ Time frames for weight loss ○ Inclusion of body composition alterations ○ Guidelines for determining competing diagnoses
    29. 29.  Caused by:  Reduced food intake  Malabsorption  Abnormal nutrient utilization and metabolism  Oxidative stress  Hormonal abnormalities  HAART treatment  Psychosocial difficulties
    30. 30.  More important than weight loss is body composition alterations  Decreased Body Cell Mass (BCM)– metabolically active, cellular component of the body, which makes up lean body mass  A loss of body cell mass of 54% is likely to result in death in HIV-infected patients regardless of the presence or absence of infectious complications.
    31. 31. HAART in AIDS Wasting Body composition changes despite weight maintenance  Lean tissue wasting  Lipodystrophy syndrome – abnormal fat distribution ○ Fat accumulates:  Abdomen  Dorsocervical – “buffalo lumps”  Breast areas ○ Subcutaneous fat loss:  Limbs  Face  Upper trunk
    32. 32. Nutrition Intervention Goals:  Preserve body cell mass  Provide adequate amounts of all nutrients for proper function  Minimize the symptoms of intestinal malabsorption Strategy  Symptom Management
    33. 33. Nutrition Assessment Should take place at diagnosis of HIV Patient-Generated Subjective Global Assessment (PG-SGA)  Dietary Evaluation  Physical Assessment  Biochemical Assessment  Medical History
    34. 34. Measuring BodyComposition Anthroprometrics  Tricep skinfold  Midarm Circumference Bioelectrical impedance analysis (BIA) ○ Convenient, inexpensive, and non-invasive method for evaluating body composition – body cell mass Dual energy x-ray absorptiometry (DEXA) ○ Measures subcutaneous and visceral fat stores
    35. 35. Biochemical Assessment Selected biochemical measures for HIV  Immunologic ○ CD4 count ○ Viral Load  Hematologic ○ Hemoglobin  Transferrin ○ Hematocrit  Albumin ○ Mean Corpuscular Volume  Prealbumin ○ Ferritin (Transthyretin)
    36. 36.  Organ Function  Cardiovascular  AST  Total Cholesterol  ALT  HDL  BUN  LDL  Creatinine  Triglycerides Endocrine  C-Reactive Protein  Glucose  Electrolytes  Insulin  Sodium  Glycoslated  Potassium Hemoglobin A1C  Testosterone
    37. 37. Energy & Protein Needs Energy – based on need to maintain weight  Harris-Benedict Formula X 1.3 (wt maintenance ) and 1.5 (wt gain)  In the presence of fever increase 13% of the BEE Protein – increased for infection  1.0 – 1.4 g/kg/day (maintenance) & 1.5 - 2 g/kg/day ( repletion)  In the presence of fever increase 10% of the total prot Needs vary depending on disease status, presence of opportunistic infection or other underlying medical conditions
    38. 38. Micronutrient Needs Dietary Reference Intakes  Vitamin A – 700-900 μg/day ○ Immune function  Vitamin E – 15 mg/day ○ Immune function – antioxidant protection  Vitamin B12 – 2.4 mcg/day ○ Cognitive function  Selenium – 55 μg/day ○ Immune function – antioxidant protection  Zinc – 8-11mg/day ○ Immune function, slowed disease progression
    39. 39. Fluids & Electrolytes Fluids : 30 -35 ml/kg (8 -12 glass) Replacement of electrolytes (sodium, potassium, and chloride) in the presence of diarrhea and vomiting.
    40. 40. Symptom Management  Nausea and Vomiting ○ Replace fluids and electrolytes ○ Bland, odorless foods ○ Beverages between meals ○ Smaller, more frequent meals ○ Reduce fatty foods with early satiety  Diarrhea ○ Replace fluids and electrolytes – juice, sports drinks, gelatin ○ Bland foods low in fiber and residue ○ Avoid fatty and gassy foods ○ Avoid lactose if problematic
    41. 41.  Anorexia ○ Eat favorite foods often in relaxed settings ○ Add flavors and an array of colors ○ Keep snacks handy ○ Appetite stimulants Oral lesions/chewing & swallowing problems ○ Moist, soft, and finely diced foods ○ Avoid spicy or acid-containing foods ○ Room temperature or cooler foods ○ Thickened liquids (swallowing) ○ Topical medicines
    42. 42. Nutrient Supplementation Specific micronutrient supplementation has shown various results, and general multivitamin supplementation is recommended, while food should be considered the main source of nutritional needs.  Double-blind, placebo-controlled trail in Thailand – 21 nutrient multivitamin (N=481) ○ Significantly reduced risk of mortality in men and women  Observational study amount HIV-infected men in U.S. taking daily multivitamin supplement (N=296) ○ 30% reduction in risk of progression to the diagnosis of AIDS ○ Significantly reduced risk for low CD4+ counts
    43. 43.  High energy, high-protein oral supplement  Prospective intervention trial (N=17) Boston, MA  Take one high-energy, high protein, oral, liquid, nutrition supplement daily for 6 weeks along with dietary counseling  Upon entry, 16 of 17 averaged 14% below UBW  10 gained weight, 2 maintained  4 lost weight – possibly due to secondary infection  Mean weight gain = 1.1 kg
    44. 44.  Glutamine (GLN) -Antioxidant Supplementation  Increase body cell mass in AIDS patients with weight loss ○ Randomized, double-blind controlled trial (N=21) ○ Patients with >5% wt. Loss since disease diagnosis ○ Treatment group: 40.0 g/d GLN, 800 mg/d ascorbic acid, 500 IU/d α-tocopherol, 27,000 IU/d β-carotene, 280 µg/d, and 2400 mg/d N-acetyl cysteine for 3 mo. ○ Treatment group gained 2.2 kg (3.2%) body weight and gain 1.8 kg in body cell mass vs .3 kg body weight and .4 kg body cell mass in control group
    45. 45. Conclusion HIV/AIDS is a complicated disease and requires critical assessment by a multidisciplinary team Maintenance of body weight and composition is crucial in delaying HIV/AIDS progression Malnutrition leading to AIDS Wasting is of primary concern in MNT Symptom management is an effective way to address factors leading to AIDS wasting Nutrient supplementation may be necessary to ensure weight and body composition maintenance
    46. 46. Questions? ? ?? ? ?? ?
    47. 47. “Do What you Can with what you Have Where you Are !”
    48. 48. Assignment…. Nutrition & Bone health Nutrition for oral & dental health MNT for psychiatric disorder
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