Title of the research project:
Nutritional Status of the People Living with AIDS
Receiving ART at BPKIHS
Details of the research project
1. Title of the research project
Nutritional Status of the People Living with AIDS Receiving ART at
To assess the nutritional status of the People Living with AIDS receiving ART at
3. Summary of the research project.
Weight loss is associated with adverse outcomes in HIV. In assessment of nutritional
status, serial weight measurement has been used by the Centers for Disease Control and
Prevention (CDC) as a way to identify the wasting syndrome. Serial measurements of
body mass index (BMI; the weight in kilograms divided by the square of the height in
meters) predicted the development of AIDS. Measurements of body compartments are
crucial in identifying persons with HIV who are at risk for serious consequences of
malnutrition. Other measures of nutritional status also predict outcome with HIV
infection. Studies by Chlebowski et al. and others showed that serum albumin levels
predicted survival. Micronutrient deficiencies are common in HIV infection. Deficiencies
in serum vitamin A, vitamin B12, selenium, and zinc, in particular, have been associated
with progression of HIV infection. Thus, measurements of serum proteins and
micronutrients can predict outcome and may identify correctable deficiencies.
Lipodystrophy, or the syndrome of fat redistribution, has been described in HIV infection
and may be related to antiretroviral therapy. Regional measures of fat must be made both
to detect changes in fat distribution and to plan intervention strategies.
Nutritional assessment in HIV-infected persons can identify those at risk for adverse
outcomes, including death, from nutritional deficiencies. Minimally invasive, proven, and
acceptable methods exist for accurate nutritional assessment. National guidelines for
adults and children with HIV are needed to provide the information and impetus for
appropriate nutritional screening and intervention in persons with HIV infection.
It is hospital based descriptive cross-sectional study conducted among the PLWA
receiving ART at BPKIHS. All the PLWA (about 200PLWA) receiving ART at BPKIHS
ART center will be included in the study.
4. Review of the literature pertaining to the project.
Malnutrition is a frequent complication of human immunodeficiency virus (HIV)
infection and is associated with a poor prognosis. To compare different measures of
nutritional status in HIV-infected patients, we prospectively studied 88 outpatients seen at
a Paris AIDS outpatient clinic for routine follow-up examinations. Nutritional status was
assessed according to body weight loss (BWL, 4 classes), anthropometry, bioelectric
impedance analysis (BIA), and subjective global assessment of nutritional status (SGA).
Malnutrition was diagnosed in 22.4% of subjects using SGA, and 37.1% by BWL. SGA
rapidly detected a worsening of nutritional status, while BWL detected malnutrition at an
earlier stage. A good correlation was found between SGA class and body composition
assessed by anthropometry and BIA. Deteriorating nutritional status diagnosed by SGA
correlated with the CDC HIV disease class. SGA, a simple nutritional assessment, can
serve as a basis for prescribing artificial nutrition, while BWL detects malnutrition at an
Globally, acquired immunodeficiency syndrome (AIDS) is an epidemic, severe and fatal
disease. Along with the etiological factors of human immunodeficiency virus infection
(HIV+) and decreased immunity, there are a number of other risk factors including
opportunistic infection, malnutrition, wasting syndrome, and oxidative stress. The
nutritional problems have been shown to be significant and contribute to health and death
in HIV+/AIDS patients. Weight loss, lean tissue depletion, lipoatrophy, loss of appetite,
diarrhea, and the hypermetabolic state each increase risk of death. The role of nutrition
and how oxidative stress is involved in the pathogenesis of HIV+ leading to AIDS is
reviewed. Studies consistently show that serum antioxidant vitamins and minerals
decrease while oxidative stress increases during AIDS progression.2
The optimization of nutritional status, intervention with foods and supplements, including
nutrients and other bio-active food components, are needed to maintain the immune
system. Various food components may be recommended to reduce the incidence and
severity of infectious illnesses by forms of bio-protection which include reduced
oxidative stress due to reactive oxygen species which stimulate HIV replication and
AIDS progression. Probiotics or lactic acid bacteria and prebiotics are sometimes given
on the presumed basis that they help maintain integrity of mucosal surfaces, improve
antibody responses and increase white blood cell production. People with HIV+/AIDS
can be informed about the basic concepts of optimal nutrition by identifying key foods
and nutrients, along with lifestyle changes, that contribute to a strengthened immune
system. Moreover, nutritional management, counseling and education should be
beneficial to the quality and extension of life in AIDS.3
Adults who are HIV-positive are more likely to be undernourished than those whose
status is not established, as there is a significant difference (P = 0.000) between the
nutritional status (BMI) of PLWHA and those whose HIV/AIDS status is not established.
PLWHA consume foods that are low in nutrients to promote their nutritional well-being
This study, which evaluated HIV infected patients with no clinical signs of AIDS, found
that majority of them had some degree of malnutrition. Malnutrition, which is often seen
at an advanced stage of HIV-infection, was a prominent feature in the early stages of HIV
infection because of the poor nutritional status of a significant percentage of individuals
in our environment. In general, the nutritional status of the normal Nigerian population is
lower compared to that of other countries. For example, a previous study states that in
Nigeria, 14% of normal females and 15% of males are underweight , which contrasts the
situation in Brazil, where 4.8% (men) and 11.7% (women) were found to be obese . The
inability of individual HIV-infected patients to meet the daily recommended dietary
allowance is more likely due to socioeconomic factors. More than a third of the HIVinfected patients in this study belonged to the lower socioeconomic status, a group
classified as “food insecure,” which is defined as not having access at all times to enough
food for an active and healthy lifestyle.5
Families affected by HIV experience the death of partner, divorce or separation and
increased household expenses due to increased health costs incurred by laboratory tests
that they must pay for themselves. The end result is more poverty and more food
insecurity. Unfortunately, these conditions may continue for some time as international
donor agencies such as the US Presidential Emergency Program for AIDS Relief
(PEPFAR) and AIDS Relief place more emphasis on the treatment of HIV with potent
antiretroviral therapy rather than on providing food supplements in addition to
antiretroviral drugs to the detriment of the nutritional status of the HIV patients. World
Health Organization (WHO) nutritional recommendations for HIV-infected individuals
emphasize the critical role of adequate nutrition for the health and survival of all subjects
regardless of their HIV stage. 6
In conclusion, malnutrition is common among HIV-infected patients. Nutritional status
has been shown to predict survival rate in adult with HIV after adjusting for CD4 count
and other secondary events. Optimal nutrition no doubt helps boost immune function and
maximize the effectiveness of antiretroviral therapy. This study will find the nutritional
status of the people receiving ART at BPKIHS and help in planning needful strategies.
5. Rational of the study.
This study will find out the nutritional status of the people living AIDS receiving ART at
BPKIHS ART centre, as nutritional problem is very common among these group of
population. Appropriate nutritional management will be beneficial for the quality of life
of the patient receiving ART.
6. Research design and methodology.
A. Research design: it will be descriptive cross sectional research design.
B. Research Setting/Sample Area: The study will be conducted at ART center of
C. Target population: All the people living with AIDS receiving ART at BPKIHS
ART center constitute the population of the study.
D. Sample and sample size:
Sample: The PLWA receiving ART at BPKIHS ART center who fulfill the set
selection criteria constitute the sample of the study.
Sample size: All the PLWA (About 200 subject) will be included in the study.
E. Criteria for sample selection/Procedure: All the PLWA on ART who give
F. Criteria for sample exclusion: Those PLWA who refuses to participate in the
study will be excluded.
G. Sampling technique: Total enumerative sampling technique will be used to
collect the data.
H. Research instrument:
Interview schedule and measurement tools will be used to collect the data.
I. Validity of the tool:
Content and face validity of the tool will be again established with the experts of
concerned field. Pre-testing of the tool will be done among 3-4 subjects. Nepali
version of the tool will be prepared and again it will be translated to English for
J. Methods of data collection/Data collection Procedure:
• A detailed list of all the cases will be prepared before starting the data
• Ethical clearance from concerned authorities (BPKIHS ethical review board)
will be obtained.
• Permission from concerned authorities i.e. HODs, In-charges etc.
• Informed written consent from each subject will be obtained prior to interview.
K. Statistical Analysis of data:
a. Descriptive data analysis: Percentage, Mean and SD will be used for
describing demographic Profile.
b. Inferential data Analysis: Chi-squire and Correlation will be used to find out
association and draw the conclusions.
L. Limitations of the study:
The study is limited to the PLWA receiving ART at BPKIHS.
M. Ethical Issues for the Research:
i. Written permission will be obtained from the concerned authority.
ii. Anonymity of the subjects will be maintained.
iii. The informed written permission will be obtained from subjects.
iv. The subjects will be assured of the confidentiality of the information.
v. Ensure privacy and confidentiality and to hide the patient’s diagnosis from
extended family members. Interview conducted in caregiver in alone, not with
patients and other family members.
5. Results and Discussion: The collected data will be entered in SPSS-12.5 software
package and will be analyzed. The findings will be presented in table and graphs.
Inferential statistics will be used to analyze and draw the conclusion. The results will be
compared with the findings of study conducted by various investigators on related fields.
6. ORGANIZATION OF THE STUDY: (TIME SCHEDULE)
Literature review and finalization of the project
Pre-testing and finalization of tool
Analysis of Data
Report writing and Submission
Details of the Budget:
Tool: Preparation, Printing & Testing.
Refreshment for Participants
Data Processing: coding and entry
Report preparation and Typing
Photocopy, Printing and Binding
Amount (In NP Rs.)
1. Chlebowski RT, Grosvenor MB, Barnhard NH, Morales LS, Bulcavage LM.
Nutritional status, gastrointestinal dysfunction, and survival in patients with
AIDS. Am J Gastroenterol 1989; 84:1288–93.
2. Grinspoon S, Corcoran C, Lee K, et al. Loss of lean body and muscle mass
correlates with androgen levels in hypogonadal men with acquired
immunodeficiency syndrome and wasting. J Clin Endocrinol Metab 1996;
3. Ott M, Fischer H, Polat H, et al. Bioelectrical impedance analysis as a predictor of
survival in patients with human immunodeficiency virus infection. J Acquir
Immune Defic Syndr Hum Retrovirol 1995; 9:20–5.
4. Palenicek J, Graham N, He Y, et al. Weight loss prior to clinical AIDS as a
predictor of survival. J Acquir Immune Defic Syndr Hum Retrovirol 1995;
5. Suttmann U, Ockenga J, Selberg O, Hoogestraat L, Deicher H, Muller MJ.
Incidence and prognostic value of malnutrition and wasting in human
immunodeficiency virus–infected outpatients. J Acquir Immune Defic Syndr Hum
Retrovirol 1995; 8:239–46.
6. Kotler DP, Tierney AR, Wang J, Pierson RN. Magnitude of body-cellmass
depletion and the timing of death from wasting in AIDS. Am J Clin Nutr 1989;
7. Wheeler DA, Gibert CL, Launer CA, et al. Weight loss as a predictor of survival
and disease progression in HIV infection. Terry Beirn Community Programs for
Clinical Research on AIDS. J Acquir Immune Defic Syndr 1998; 18:80–5.
8. Guenter P, Muurahainen N, Simons G, et al. Relationships among nutritional
status, disease progression, and survival in HIV infection. J Acquir Immune Defic
Syndr 1993; 6:1130–8.
9. Centers for Disease Control and Prevention. 1993 revised classification system
for HIV infection and expanded surveillance case definition for AIDS among
adolescents and adults. MMWR Morb Mortal Wkly Rep 1992; 41(RR-17):1–19.
10. Maas JJ, Dukers N, Krol A, et al. Body mass index course in asymptomatic HIVinfected homosexual men and the predictive value of a decrease of body mass
index for progression to AIDS. J Acquir Immune Defic Syndr 1998; 19:254–9.
11. Paton NI, Castello-Branco LR, Jennings G, et al. Impact of tuberculosis on the
body composition of HIV-infected men in Brazil. J Acquir Immune Defic Syndr
Hum Retrovirol 1999; 20:265–71.
12. Semba RD, Caiaffa WT, Graham NM, Cohn S, Vlahov D. Vitamin A deficiency
and wasting as predictors of mortality in human immunodeficiency virus–infected
injection drug users. J Infect Dis 1995; 171: 1196–202.
13. Tang AM, Graham NM, Chandra RK, Saah AJ. Low serum vitamin B-12
concentrations are associated with faster human immunodeficiency virus type 1
(HIV-1) disease progression. J Nutr 1997; 127:345–51.
14. Baum MK, Shor-Posner G, Lai S, et al. High risk of HIV-related mortality is
associated with selenium deficiency. J Acquir Immune Defic Syndr Hum
Retrovirol 1997; 15:370–4.
15. Baum MK, Shor-Posner G, Campa A. Zinc status in human immunodeficiency
virus infection. J Nutr 2000; 130:1421S–3S.