HIV and Nutrition.ppt

HIVandNutrition,NigelRollinsDepartmentofPaediatricsandChildHealth,Newvariantfamine:AIDSandfoodcrisisinsouthernAfrica.AlexdeWaalandAlanWhiteside.Lancet2019;362:1234-37,SecondaryeffectsoftheAIDSepidemiconfoodsecurity,famineandnutritioncouldbeasgreatastheprimaryeffectsPresentsouthernAfricadroughtandfoodcrisiscompoundsAIDSepidemicHistoricalcopingstrategiesareindangerofcollapsing.PresentfoodcrisismoreintractableHighdegreeofvulnerabilityinareasnotaffectedbydroughtHouseholdimpoverishmenthasoccurredmorerapidlyDespiteearlyrainsinearly2019,highlevelsofvulnerabilitypersist,Hypothesis:HIVaccountsforwhymanyhouseholdsarefacingfoodshortageandexplainsgrimtrajectoryoflimitedrecoveryAlreadyknown:HouseholdaffectedbyAIDSmorbidityandmortalityloseincome,assets,andskills;chronicallysickmemberresultsin30-35%onaveragereductioninannualincomeFourproposednewfactors,Household-levellabourshortagesareattributabletoadultmorbidityandmortalityasistheriseinnumberofdependants,Contest:ProjectionsdonotsuggestdemographiceffectofHIV/AIDSonchangesindependencyButthesedonotconsider:ClustereffectsatthelevelofthehouseholdAgeandsexdistributionofpopulationaffectedbyHIVNon-productivityofsickadults,Lossofassetsandskills,Skillsarelostnotjustinthelabourmarketbutalsointhehome.Foodsecurity,preparationandcopingstrategies,Theburdenofcare,SickadultsandoforphansMajorexpenditureDiversionofresourcesandlabour,MalnutritionandHIV,“UndernourishedindividualsaremoresusceptibletobeinginfectedwithHIVandfortransmission”?“MalnutritionthusthreatenstoaccelerateprogressionfromHIVtoAIDSformillionsofindividuals”?“ThisfactimpliesthatplansforintroductionofARVRx.onalargescaleshouldbecombinedwithnutritionalsupportprogrammes.”,Otherinfluences,VariousguidelinesemergingSomerecommendingupto100%extraproteinOpportunisticmarketIpap;Moducare;ExtravirginoliveoilARVsNocommentinWHOdraftguidelinesonARVsindevelopingcountries,Whatisknown?,GrowthandHIVEnergyexpenditure/whywastingInterventionsMicronutrientsTransmissionDiseaseprogression,Energyexpenditure,Restingenergyexpenditure(REE)Basalmetabolicrate(BMR)Totalenergyexpenditure(TEE)Exerciseandadditionalmetabolicdemands(Activity-relatedenergyexpenditure-AEE),GrowthofinfantsborntoHIV-infectedwomen,NodifferenceingrowthparametersatbirthProgressiveweightandlineargrowthfailureInfantswhodiedwereseverelymalnourishedandstunted,Earlynutritionalinterventionsmighthelppreventearlyprogressionordeath,Bobat2019,GrowthofinfantsborntoHIV-infectedwomen,NodifferenceingrowthpatternsbetweenHIV-uninfectedchildrenofinfectedmothersandun-exposedinfantsProgressivelossingrowthvelocityBy10years,7kgand7.5cmdifference,ARVsimprovegrowth,Newell2019,GrowthofinfantsborntoHIV-infectedwomen,ReducedW/AandL/AofinfectedchildrenwhodiedW/Az-score-1.5x5deathovertwoyears,Whatistheeffectofearlyaggressivenutritionalintervention?,Behrane2019,GrowthofinfantsborntoHIV-infectedwomen,InfantsborntoHIV-infectedwomenaresmallerREEandTEEnormalIncreasedHIVRNAassociatedwithpoorgrowth,DailyintakeseemsinadequateforgrowthbutnotthesolefactorWhatistheroleofanabolicsteroids?,Arpadi,Intakeandexpenditure,REEnormalIntakenormalBodycompositionnormal,.nothypermetabolicwhenthereisnointercurrentinfection,Alfaro2019,Expenditureandgrowth,DecreasedREEinHIV-infectedchildrenwithdecreasedgrowth,Henderson2019,Bodycompositionanddiseaseprogression,Miller1993,Adult:decreasedLBMpredictsdeath,Lossofleanbodymassprecedesadeclineinweight,Wholebodyproteinturnover,AssociatedwithW/AandH/AanddietaryproteinintakeNotrelatedtoREEorCD4countsProteinbalancevariedwithenergyandproteinintake,CanachievepositiveproteinbalanceifadequateintakeSuggestedadequateintakemayresultinadequateweightandheight,Henderson2019,AdultsREEandTEE,IncreasedREE5%higherthanpredicted,veryillpatientsCD4=30.PatonClinSci2019;91:241-5.IncreasedREE14%higherthanpredictedinmalnourishedHIVpatients.MelchiorAJCN1991;53:437-41IncreasedREEby9%inpatientswithHIVAIDSandARCcomparedtocontrolswithsimilarbodycomp.HommesMetabolism1990;39:1186-90IncreasedREEby8%inearlystageHIVpatientswithnormalCD4.HommesAJCN1991;54:311-5.IncreasedREEHIV(11%),AIDS(25%),AIDSSI(29%).Caloricintakereduced36%inAIDSSI(secondaryinfection).GrunfeldAJCN1992;55:455-60.REE11%higherinmalnourishedHIVwithoutsecondaryinfectionand34%higherinHIVwithsecondaryinfection.MelchiorAJCN2019;57:614-9.REEincreased8%duringweightlossinHIVpatients.SuttmanMetabolism199342:1173-9.,REEnotincreasedandwaslowerinHIVpatientswithweightloss.SchwenkNutrition201912;595-601.IncreasedREEinasymptomaticHIV-infectedmen.SharpstoneAIDS2019;10:1377-84.TEEthesamebutREE10%higherinweightstableHIVpatients.HeijligenbergMetabolism201946;1324-6.REEdecreasedinHIVpatientswithmalabsorption.Jimenez-ExpositoAIDS201912;1965-72.IncreaseinREEwithfirstdiagnosisofAIDS.SharpstoneAIDS201913;1221.IncreasedREE/kgleanbodymass10%inHIV.BattterhamEJCN201957:209-217.REEandTEEdecreasewithweightloss,butdecreaseincaloricintakegreater.Morenegativeenergybalanceinweightlossgroup.Macallan;NEJM2019;333:83-8.,Currentconsensus,Restingenergyexpenditureinadultsisraisedby10%fromthetimeofinfectionNotsimilarlydemonstratedinchildrenTotalenergyexpendituremaybedecreasedbecauseofinactivity(Activity-relatedenergyexpenditure-AEE)GrowthfailureisnotsolelyrelatedtoenergyrequirementReducedintake,especiallyduringconcurrentinfectionsisprobablythemainfactorthatresultsinwasting,WHOrecommendations,Adults:energyneedsareincreasedby10percentoveracceptedrequirementsforotherwisehealthypeoplesymptomaticHIVinfectedadultsthosewhohavetransitionedtoAIDS,anincreaseinenergyintakeofabout20to30percenttomaintainbodyweightisrecommendedduringperiodsofsymptomaticdiseaseoropportunisticinfectionHardtoachieveduringacuteillness-requirementsshouldthereforebemaximizedduringtherecoveryphase,WHOrecommendations,Children:Energyintakeshouldbeincreasedby10percenteventhoughdatanotavailabletosupportSymptomaticHIVinfectedchildrenwithchronicillnessese.g.LIPorTBshouldincreaseenergyintakebyabout20to30percentEnergyintakesforHIV-infectedchildrenexperiencingweightlossneedtobeincreasedby50to100percentoverestablishedrequirementsforotherwisehealthyuninfectedchildren,TheserecommendationsshouldbeachievedasmuchaspossiblethroughdietaryapproachesratherthanspecificnutritionalproductsInadequatedataonproteinturnovertosubstantiateclaimsofneedtoincreaseintakeby25-100%.Proteinshouldprovide12-15%oftotalcalorieintake,Tubefeedingandgrowth,Tubefedfordysfunctionalswallowing,aspirationorGOR(n=18)Medianduration8.5monthsResultedinsignificantlyincreasedW/A,W/HandarmfatareaDidnotalterH/Aorarmmusclearea,Tubefeedingwasnotsufficienttocorrectlineargrowth,Henderson1994,NGandGastrostomyfeeding,Anthropometricdata,caloricintakeandCD4counts(n=23),beforeand6monthsafterNGchangedtogastrostomyfeedingCaloricintakeimprovedwithbothGastrostomyimprovedW/AandW/Hbutnotheight,skinfolds,AMC,hospitaldaysorCD4HigheradjustedCD4countsandlowerW/Hpredictedresponse2.8foldriskreductionofdyingforeverypositiveunitchangeinweightzscore(p=0.005),Gastrostomysupplementationcanimproveweightandfatwhenothermethodsfail,Miller2019,N-3fattyacidenrichedfeeds,Enterotropicpeptide-based,n-3fattyacid-enrichedformulaRCT-standardvs.n-3formula(n=74adults)Bothsupplementsimprovedweightover3monthsmainlyfatCD4576(+-403)vs.642(+-394)(p0.05)Fewerhospitaldaysinn-3groupNS,N-3fattyacidandpeptideenrichedformulamayincreaseCD4counts,DeLuisRoman2019,Enteraland/orparenteralnutritionalrehabilitation,DatacollectedbyquestionnairescirculatedtoHIVreferencecentres16childrenreceivedENand46TPNChildrenreceivingTPNhadworsebaselinecharacteristicsENimprovedbodyweight,CD4andxyloselevels.SimilartrendswithTPN,NutritionalsupportmayimproveCD4countsandrestoreintestinalabsorptionBettertoprovidesupportbeforeterminalstage,Guarino2019,Nutritionalrehabilitationandmortality,Retrospectivestudy(CdI)of193malnourishedchildren(80HIV+)Malnutritionprogramme(oralfeedsexcl.vitaminsandmicronutrientsupplements)improvedoutcomesinHIV-butnotHIV+,ClinicalstudiestoimprovethenutritionalmanagementofHIV-infectedchildrenindevelopingcountriesareneeded,Beau2019,FawziW.GlobalStrategiesforthePreventionofHIVTransmissionfromMotherstoInfants.2019;Canada:p.45,Micronutrientsandverticaltransmission,Multivitaminsresultedinlargeandsignificantreductionsintheriskof:foetaldeathlowbirthweightsevereprematuritySignificantandsustainedimprovementsinCD4andCD8cellcounts,RISKOFVERTICALTRANSMISSIONOFHIV-1AMONG700WOMENINMALAWIVITAMINATRIAL,Kumwenda,ClinInfectDis2019;35:618,ESTIMATEDPROBABILITIESOFHIVINFECTIONBYTREATMENTGP.SOUTHAFRICANVITAMINASTUDYN=630,*Estimatedwiththedelta-methodapproximationfromreportedproportionsand95%CIsinCoutsoudisAIDS2019;13:1517,EFFECTOFMULTIVITAMINSUPPLEMENTATIONONHIVINFECTIONANDMORTALITYOUTCOMESOFOFFSPRING,Fawzi,AIDS2019;16:1935,Fawzi,AIDS2019;16:1935,EFFECTOFVITAMINASUPPLEMENTATIONONHIVINFECTIONOFOFFSPRING,EFFECTOFVITAMINSUPPLEMENTSONHIVINFECTIONTHROUGHBREASTFEEDINGAND/ORDEATHBY24MONTHS(survivalanalysis),Fawzi,AIDS2019;16:1935,Whythedifferenceofeffect?,?Ironsupplementation,MULTIVITAMINSDECREASEDTHERISKOFINFECTIONTHROUGHBREASTFEEDINGINPOPULATIONSUBGROUPS,Fawzi,AIDS2019;16:1935,MULTIVITAMINSDECREASEDTHERISKOFDEATHBY24MONTHSINPOPULATIONSUBGROUPS,Fawzi,AIDS2019;16:1935,LYMPH,LYMPH,VITE9.6mol/L,RELATIVERISK,VITE9.6mol/L,P=0.05,P=0.008,CochranereviewofmicronutrientsandHIVdiseaseprogression,Inprogress32trialsincluded1/7studiesreportingonall-causemortalityfoundareductionduetovitaminAsupplementsof63%inHIV-infectedchildren(RR=0.370.14,0.95)Multivitaminsupplementation(B,C,E)ofBFmothersreducedchildmortalityamongimmunologicallyandnutritionallycompromisedwomeninonetrialOneoffourstudiesreportingonmorbidity(includingdiarrhoea,RTIsandHIV-relatedsymptoms),founda49%reductionofalldiarrhoeainHIV-infectedchildrenduetovitaminAChangesinHIV-1viralloadorCD4countsandotherlymphocytesubsetswerereportedin8and10studiesrespectively.NochangeinVLreportedandvariableresponsesinT-cellsubsets,Theeffectofmicronutrientsonall-causemortalityandonmorbidityinHIV-infectedadultsandchildrenappearstobeindependentoftheireffectonHIVviralloadorimmunemarkers,ObservationalstudiesonmicronutrientsandHIV,LowbloodlevelsanddecreaseddietaryintakesofsomemicronutrientsareassociatedwithfasterHIVdiseaseprogressionandmortality,andwithincreasedrisksofHIVtransmission(?causal:vitaminAandMTCT/Znandmortality)Micronutrientsupplements,suchasvitaminsB-complex,C,andE,canimproveimmunestatus,preventchildhooddiarrhea,andimprovepregnancyoutcomes,includingmaternalprenatalweightgain,fetalloss,prematurity,andlowbirthweight,WHOrecommendations,HIV-infectedadultsandchildrenareencouragedtoconsumediets,whichensuremicronutrientintakesatRDAlevelsSeveralstudiesraiseconcernsthatsomemicronutrientsupplements,suchasvitaminA,zinc,andiron,mayproduceadverseoutcomesinHIV-infectedpopulatio