|HIV and nutrition|
|Ngonut: HIV vitamins and survival||Andre Briend||04.06.98|
|severe malnutrition and HIV||Michael Golden||31.05.98|
|HIV and nutrition||Andre Briend||05.06.98|
|HIV and malnutrition, Food vs infection||David Brewster||05.06.98|
|Re: HIV and malnutrition, Food vs infection||Colin Ball||04.06.98|
|Request for information on Nutrition and survival for PLHIV||David Chipanta||18.06.98|
|FW: nutrition and AIDS||Florence Egal||03.09.98|
Date: Thu, 4 Jun 1998 16:18:10 +0200 (METDST)
From: briendatext.jussieu.fr (Andre' BRIEND)
Subject: Ngonut: HIV vitamins and survival
Regularly I am asked by NGO's if, as a nutritionist, I have advice to give to feed HIV+ and AIDS patients. I turn to NGO'nut to get advice myself on this difficult problem. To me, there are two different issues at stake.
1- Treatment of severe malnutrition associated with AIDS.
>From available literature, I suspect that general principles guiding the treatment of severe PEM remain valid in case of AIDS. I am afraid the long term prognosis, in this case, will be more related to the availability of anti HIV drugs than to the type of nutritional support but improvement should be possible on the short term. In any case, I would think that the standard treatment based on F100 (if acceptable to adult patients) should be appropriate from the nutritional point of view. Any more informed opinion on that ?
2- Improving survival of HIV+ patients
There is an abundant literature suggesting (on indirect but consistent evidence) that vitamin and mineral supplementation may improve survival of HIV+ patients, even in rich countries where there is little likelihood of primary malnutrition. Unfortunately, there are virtually no controlled trials to support this hypothesis : as soon as this preliminary information became available to the AIDS community, the use of these supplements became so common in HIV+ patients that it became impossible to make a proper control group to assess their efficacy. Vitamin mineral supplements are very cheap compared to usual HIV therapy, and they seem virtually risk free. So, at least in rich countries, why wait for controlled trials, in face of an even remote minor possibility of improved survival when there is virtually no cost and no risk ? In any case, this debate is now out of fashion in rich countries, since tri-therapy completely changed the whole picture. I do believe though that the issue remains relevant in developing countries with no access to modern treatment.
Accumulation of data on the benefits of vitamins and minerals for HIV patients continues:
Recently, two papers examined prospectively the association between vitamin intake and survival. This approach is much more convincing than the often reported association between serum markers of vitamin status and survival (coming out all the time). They suggest that supplements, especially group B vitamins (apparently B6), make a difference in terms of survival. Zn seems to have unfavourable effects.
Tang AM, Graham NM, Saah AJ. Effects of micronutrient intake on survival in human immunodeficiency virus type 1 infection. Am J Epidemiol 1996;143(12):1244-56.
Tang AM, Graham NM, Kirby AJ, McCall LD, Willett WC, Saah AJ. Dietary micronutrient intake and risk of progression to acquired immunodeficiency syndrome (AIDS) in human immunodeficiency virus type 1 (HIV-1)-infected homosexual men. Am J Epidemiol 1993;138(11):937-51.
On May 17th in the Lancet, a randomised trial from Tanzania ( ...a randomised trial... please note: difficult to get a placebo group in rich countries) showed benefits of vitamin supplementation in pregnant women in Tanzania in terms of pregnancy outcome and CD4 count.
There are many papers suggesting that selenium deficiency is especially common in HIV patients, and some show that AIDS patients benefit from selenium supplementation (see below as an example). Selenium deficiency seems quite common in the tropics.
Zazzo JF, Chalas J, Lafont A, Camus F, Chappuis P. Is nonobstructive cardiomyopathy in AIDS a selenium deficiency-related disease? [letter]. JPEN J Parenter Enteral Nutr 1988;12(5):537-8.
At this stage, I have several queries :
Has any nutritional NGO / UN agency clear guidelines / policy re: nutritional care of HIV+ patients ? If yes, can we know more about it ?
Vitamin of the B group are usually cheap, even by developing country standards. There is apparently no risk of supplementation with moderate doses. Should we wait for further evidence before advising inclusion of B vitamins in patient support programmes being setting up in many places ? A controlled study takes several years. Apart from the on going studies on mother to child transmission is there any study going on on vitamin supplementation and passage to HIV+ latent infection to AIDS ? What about other nutrients ? Where to draw the line between cheap, safe, and presumably slightly effective supplementation and those in need of further evaluation ?
Dr. Andre' Briend
Date: Sun, 31 May 1998 14:26:22 +0100
From: Michael Golden m.goldenatabdn.ac.uk
Subject: Ngonut: severe malnutrition and HIV - treatment
Andre' raises two very important questions. In terms of Treatment of severe malnutrition associated with AIDS I offer two observations.
a) in the early stages of the epidemic in Jamaica we had several children who failed to improve after we diagnosed HIV infection. As there was nothing specific to offer these children and there were social issues involved etc. we decided NOT to test any child on admission - but we did measure the HIV status of children on discharge from the ward (or death).
By the time I left Jamaica in 1991 there had been 12 HIV positive cases diagnosed on discharge. (one interstitial lymphocytic pneumonia diagnosed as HIV prior to discharge and one in a death giving 14 cases all together).
The clinical course of the HIV positive patients was identical to the HIV negative ones in terms of admission anthropometry, length of time ot regain appetite, amount of weight loss after admission, time to minimum weight, rate of weight gain, length of stay in the ward and intercurrent infections during recovery.
When the staff did not know that the patients were HIV positive there was no difference. For the early children where the staff did know the diagnosis this did seem to make a difference. It was from this experience that the guidelines were written into the draft manual for the management of severe malnutrition along similar lines.
b) I have been examining the distribution of the rates of weight gain of children from Therapeutic Feeding Centres run by Action Contra la Faim in Africa. The HIV status of none of these children is known and the status is not measured on discharge. I was particularly looking to see if the distributions indicated whether the children were drawn from one or two populations on the basis that if the HIV positive children responded differently to treatment then they should form a subpopulation. The distribution was gaussian - there is no indication so far of a subpopulation of non-responders to treatment that is distinctly different from the rest of the children. In North Uganda the prevalence of HIV is about 10% (and probably higher in the severely malnourished population due to selection bias) - I would have expected to see a non-gaussian distribution if these children responded differently.
Although I am not aware of other studies that address this point more formally, it would seem that the same treatment should be given to all severely malnourished patients irrespective of their HIV status.
Prof. Michael H.N.Golden
Date: Fri, 5 Jun 1998 12:55:21 +0200 (METDST)
From: briendatext.jussieu.fr (Andre' BRIEND)
Subject: Ngonut: HIV and nutrition
I feel the major issue re: HIV patients in developing countries is the possible effect of vitamins and minerals to delay the onset of AIDS, realted complications and death. In terms of public health, this seems to me much more important than nutritional support of AIDS patients. If giving B vitamins + selenium can really make a difference, in absence of modern antiviral therapy (which is the case for maost patients) this is worth considering. Opinions on this difficult topic welcome.
My questions re: AIDS associated malnutrition related more to adult feeding than to children. Again, feedback welcome. Jean Pierre Beau who worked in Cote d'Ivoire also said, as Mike, that weight gain of these children, on first treatment, was comparable to HIV- children. But as David said, they relapsed, and then mortality figures were very high.
Dr. Andre' Briend
Date: Fri, 05 Jun 1998 12:17:59 +0930
Subject: Ngonut: HIV and malnutrition, Food vs infection
1. HIV and Malnutrition
We were constantly facing the problem of PEM and HIV in Malawi in
Paediatrics (where over 30% of pregnancies were in HIV+ women) and we
developed a rather different attitude from these circumstances and the
very limited resources available for the hospital management of severe
malnutrition. So I would argue against the possibility of sweeping
generalisations on this issue.
A Conference on the treatment of childhood malnutrition in refugee
camps recommended that if HIV testing was done at all, it is best
delayed until after nutritional rehabilitation. [Briend A, Golden MH.
Treatment of severe child malnutrition in refugee camps.
Eur.J.Clin.Nutr. 1993;47:750-4.] This approach may be appropriate in
many but not all circumstances, and it does not necessarily promote
good clinical practice. Case management at NRCs must be based on
accurate diagnoses, since malnutrition is the final common pathway for
a host of disease processes. Nutritional rehabilitation is expensive
and should be targeted to those most likely to benefit. Malawi's child
health care services can ill afford the luxury of hospitalising all
wasted HIV cases until death, nor is it in keeping with the desires of
affected families. Triple therapy or even single therapy with AZT is
out of the question
There is a major age difference in the result of nutritional
rehabilitation without AIDS-specific therapy. The young infant with
PCP will never benefit, and are often not malnourished (we saw several
every week). From the perspective of a hospital treating severe
malnutrition, the 8-15 month old with growth failure from HIV
infection (including microcephaly) had at best a transient
improvement, but none as the disease progressed and there seemed
little point in keeping them months in hospital with no weight gain.
From a community perspective, however, they might be picked up earlier
and benefit from ambulatory supplementary feeding. Finally, the older
child with HIV is more like adults and should receive as good
treatment as possible until end-stage. I have appended a summary of
Paediatric HIV presentations at the end out of interest.
2. Food intake vs Infection
David Werner's comments on "lack of food rather than frequent
diarrhoea" causing malnutrition cannot go unchallenged, and certainly
do not represent Andre Briend's views (as I expect he will reply).
This is a bit like the old nature-nuture debate. But I would like to
make people aware of a growing literature showing the importance of
subclinical malabsorption as a contributor to malnutrition,
especiallly stunting. In particular, the studies by Lunn indicate
abnormal intestinal permeability and lactose malabsorption are key
factors in growth failure. Chronic giardiasis and cryptosporidiosis
are also important in causing failure to thrive, even without
diarrhoea in giardiasis. So diet is not the whole story, and it is
difficult for mothers to give the increased requirements for catch up
growth with infection and anorexia.
David Brewster, Clinical Dean
NT Clinical School, Darwin, Australia
1 Bhan MK. The Gut in Malnutrition. In: Walker WA, Durie PR,
Hamilton JR, Walker-Smith JA, Watkins JB, editors. Pediatric
Gastrointestinal Diseases: Pathophysiology, Diagnosis, Management.
2nd ed. St Louis: Mosby; 1996; 26, p. 867-78.
2 Lunn PG, Northrop Clewes CA, Downes RM. Intestinal permeability,
mucosal injury, and growth faltering in Gambian infants. Lancet
3 Molbak K, Andersen M, Aaby P, Hojlyng N, Jakobsen M, Sodemann M, da
Silva AP. Cryptosporidium infection in infancy as a cause of
malnutrition: a community study from Guinea-Bissau, west Africa.
4 Northrop Clewes CA, Lunn PG, Downes RM. Lactose maldigestion in
breast-feeding Gambian infants. J.Pediatr.Gastroenterol.Nutr.
Appendix: HIV Paediatric Presentations in Malawi
1. PCP (pneumocystis carinii pneumonia).
- age 3-8 months
- cough, tachypnoea, respiratory distress and clear lung fields
(no crackles or wheezes)
- usually no malnutrition or adenopathy
- no response to penicillin or chloramphenicol
- acute bronchiolitis with wheeze
- acidosis from herbal poisoning (usually given to treat diarrhoea)
2. Failure to thrive (FTT) in a breastfed infant (<12 months).
- normal growth after birth with faltering around 3-6 months of age
on the Under 5 Card
- maternal lactational problems (e.g. stopped breastfeeding,
insufficient breastmilk, chronic illness)
- congenital abnormalities (usually with intrauterine growth
3. Marasmus or marasmic-kwashiorkor.
- wasting or thinness
- marked poverty and illiteracy in the parents
- inadequate food supply or early weaning from breastfeeding
- sustained improvement on nutritional rehabilitation
- NB Chronic diarrhoea and oral thrush are also common in
HIV-negative primary malnutrition
4. Suspected PTB in an infant with no sputum positive contacts.
- note that TB tends to be overdiagnosed in children
- suspect HIV if no weight gain after 4 weeks TB treatment
- N.B. There is disagreement even among Paediatricians about TB
diagnosis, but we all agree that it would be tragic to miss TB in an
5. Uncommon but important diagnostic syndromes (mostly in older
- Shingles (Herpes zoster)
- Kaposi sarcoma
- Cryptococcal meningitis
- Lymphoid interstitial pneumonitis (LIP)
- Recto-vaginal fistula or genital ulcers
1. Severe oropharyngeal candidiasis
2. Generalised lymphadenopathy, especially axillary nodes
3. Persistent fever
4. Chronic cough
5. Chronic papular dermatitis
6. Chronic / recurrent diarrhoea
7. Microcephaly with developmental delay or regression
8. Recurrent respiratory, CNS or skin infections
9. Parotid gland enlargement (chronic non-suppurative)
Epidemiologic risk factors
1. Previous child died after two months of age of a suggestive illness
2. A parent died or is chronically ill (including TB)
3. History of transfusion with unscreened blood
Date: Thu, 04 Jun 1998 06:31:35 +0100
From: Colin Ball, LLABNILOCataol.com (by way of Michael Golden LLABNILOCataol.com)
Subject: Re: HIV and malnutrition, Food vs infection
Dear Dr Brewster, I enjoyed reading your message and advice on the handling of children with HIV and malnutrition. I am sure that appropriate interventions must be determined not only by scientific evaluation or perceived optimal treatment regimes, but also put into the context of local resources. Your clinical observations in Malawi, however, bear a great deal of resemblance to clinical HIV related syndromes I have seen in London, and I have two comments:
1. Infants presenting with PCP as an AIDS defining illness in the first year of life have undoubtedly responded in a different way to the HIV virus immunologically than older children- they are "rapid progressors" and often have extremely high viral load, and relatively preserved CD4 counts. It is not surprising that such children rarely present with FTT, which I find you are more likely to see in older children with slower progressing disease, LIP, lymphadenopathy, hepatosplenomegally, atopic diseases, recurrent thrush, VZ disease, and recurrent bacterial illnesses and lower viral load and CD4 counts. I feel that infection UNDOUBTEDLY plays a significant part in the wasting disease of AIDS and is perhaps to an extent modulated through the immunological response with influences on interleukins and other cytokines like TNF alpha.
2. In ( as yet unpublished research) in our clinic, I have demonstrated malabsorption occuring in even relatively well children with HIV infection (CDC class A) associated with the onset of weight loss, and have reversed this in a CDC class C disease child with subtotal villous atrophy using intravenous nutrition and 4 drug combination therapy. This suggests to me, in the absence of ANY positive cultures that HIV could have a direct effect on the function of the small intestine- I would wonder whether EARLY nutritional intervention could help prevent disease progression. I suspect that most micronutrition observations are SECONDARY events related to the immune response, rather than dietary deficiency.
In countries with high endemicity of HIV infection in children, it must be very difficult to know how to devise the most appropriate physical and emotional strategy for dealing with the problems that these children present.
Prevention has to be the primary aim, which in vertical transmission means improving maternal health first, examining the role of breast feeding in postnatal transmission, and devising economically viable interventions to reduce mother to child transmission.
Nutrition is indeed a final common pathway, but the HIV virus may influence nutrition directly and indirectly in a number of ways. The direct efficacy of combination antiviral treatment should not be underestimated, but it is sadly a privilage for the few rather than the many.
Colin Ball- Department of Child Health King's College Hospital London.
From: David Chipanta napnzpatzamnet.zm (NAP+/NZP+)
Subject: Ngonut: Request for information on Nutrition and survival for PLHIV
I am the President of the Network of African People Living with HIV/AIDS(NAP+) and I also co-ordinate the Network of Zambian People living with HIV/AIDS (NZP+). I have been asked by the Organisers of the Geneva conference to make a presentation on Nutrition and Long term survival. Please help with me information on this topic.
courtesy of ZAMNET Communication Systems Limited Box 32379, Lusaka telephone: +260-1-290358(admin) +260-1-293317(support)
Date: Thu, 03 Sep 1998 11:04:00 +0200
From: "Egal, Florence (ESNP)" <Florence.Egalatfao.org>
Subject: Ngonut: FW: nutrition and AIDS
One of my colleagues is asking for material/publications on this topic to send to an NGO in Kenya. I would welcome your suggestions.
Florence Egal, (Nutrition Programmes), Food and Nutrition Division, FAO
via delle Terme di Caracalla, 00100 Rome Italy
tel (+39) 6 570.53126, fax (+39) 6 570.54593, email florence.egalatfao.org