November 2003 Public Health HIV/AIDS Journal Club

?“HIV and Nutrition?” was the topic addressed by paediatrician Dr Nigel Rollins in his presentation to the November 2003 session of the Public Health HIV/AIDS Journal Club, held at the Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine in Durban.

Dr Rollins, an acclaimed specialist in infant feeding and nutrition, began by observing that a great deal of ?“lip-service?” was being paid to the need for adequate nutrition in relation to support for HIV-infected and AIDS-afflicted patients, but that a serious review of specific facts in this regard, with a particular focus on the needs of babies and young children, should be undertaken.

He referred to a recent article by Alan Whiteside and Alex de Waal published in The Lancet (2003; 362: 1234-37) in which they describe ?“a new variant famine?” as constituting the collateral damage caused to populations and communities arising from the secondary effects of food insecurity and HIV/AIDS. Established knowledge about the primary effects on households as a result of AIDS morbidity and mortality, (i.e. loss of income, assets, and skills, with chronically sick family members resulting in an average reduction in annual income of 30-35%) is now being compounded by newly proposed factors:

• Household-level labour shortages and a rise in the number of dependants
• Loss of assets and skills: not only labour market but also in the home, which impacts on food security, preparation and coping strategies
• The burden of care: (of sick adults and orphans, incurring major expenditure and diversion of both resources and labour)


These factors indicate that there is a much broader story to be told around the patient one encounters in the hospital ward. Dr Rollins also noted that while the migrant labour system and other historic socio-economic factors gave rise to the loss of the father as a family role-model, the HIV/AIDS epidemic is now causing the loss of the mother as well, leaving children virtually bereft of these important bonds.

On the subject of malnutrition and HIV/AIDS, he said that although certain assumptions prevailed as to the need for plans around the introduction of ARV therapy on a large scale to be combined with nutritional support programmes, there was no established causal relationship between the two clinical conditions. Not enough is known yet as to whether under-nourished individuals are more susceptible to HIV infection or whether malnutrition accelerates the progression of HIV to AIDS.

Other points characterising the debate around nutrition and HIV/AIDS include opportunistic market forces touting nutrient-based immune-boosting products, and the fact that there was insufficient data available on the benefits of increasing protein intake by 25% to 100% as an adjunctive programme to support ARV drug regimes for patients in developing countries (the WHO guidelines on ARV roll-out not having mentioned this aspect of care).

Dr Rollins then outlined, through a review of relevant literature and current research consensus, what IS known about the role of nutrition in the growth of infants born to both HIV-positive and HIV-negative women, energy expenditure (why wasting occurs), interventions, and which micronutrients (or the lack thereof) influence HIV transmission and disease progression.

He summarised the World Health Organisation?’s recommendations on energy intake for adults and children, mentioning that achievement of these intake levels through dietary approaches rather than specific nutritional products was favoured. He also presented studies on tube feeding and growth, gastrostomy feeding to increase weight and fat, the role of N-3 fatty acids and peptide-enriched formula in raising CD4 counts, enteral and/or parenteral nutritional rehabilitation, and how multivitamin intake might result in significant and sustained improvement of CD4 and CD8 counts.

A number of priorities for further research could be determined regarding the impact of HIV infection on nutritional levels, including:


• the effect of HIV infection on macronutrient needs, particularly protein and fat requirements
• whether energy requirements for people living with HIV/AIDS vary in different stages of disease, and for those with opportunistic infections
• whether there are higher energy requirements for HIV-infected children and pregnant and lactating women
• the effects of HIV infection on micronutrient requirements among children and adults
• whether maternal HIV infection affects fetal endowment of nutrients and breast milk composition
  
  Studies are also needed on the role of nutrition in HIV infection, specifically:
  
  
• optimal levels of energy and protein intake during metabolic stress
• optimal nutrient guidelines for patients with chronic diarrhea or gastro-intestinal infection
• the effects of nutritional intervention on prevention of opportunistic infections and slowing of disease progression in HIV infection


Operational research questions requiring investigation include:


• how food and nutritional support programmes should be specifically designed for patients presenting with HIV/AIDS
• determining effective packages of nutritional interventions for food security and livelihood programmes to mitigate the nutritional impacts of HIV caused by reduced agricultural productivity and/or earning capacity.


In summing up, Dr Rollins stressed the need to know how one would target and monitor vulnerable households and how one would budget for such programmes. He expressed doubt as to whether this research would ever be adequately undertaken through formal scientific protocols, and where the momentum for these studies would come from.

?“Multivitamins are not cheap,?” he said, ?“and although the main treatment focus is on anti-retroviral therapy at the moment, one can?’t consider putting very young children onto lifelong ARV regimes, nor should we underestimate the side-effects of these drugs.?”

?“It would be preferable to work on the design of balanced food packages which would include some pre-mixed multivitamin formula products, especially for children,?” he said. However, daily realities such as the effects of high humidity levels in Durban and surrounding areas on storage of multivitamins in poor households were difficult to address. ?“Bottled multivitamins become unstable if they are not refrigerated,?” he pointed out. Prof Jerry Coovadia suggested that the best study to be contemplated would be one focusing n a multi-nutrient intervention for populations in developing countries.

The full report can be downloaded on the righthand side of this page

(For the PowerPoint version of Dr Rollins?’ presentation, which includes details of the research data covered by his talk, click on the link in the right-hand column.)