Practice Paper of the Academy of Nutrition and Dietetics: Nutrition Intervention and Human Immunodeficiency Virus Infection.

Nutrition is an integral component of medical care for people living with human immunodeficiency virus (HIV)/autoimmune deficiency syndrome (AIDS) (PLWHA). The Academy of Nutrition and Dietetics supports integration of medical nutrition therapy into routine care for this population. Fewer PLWHA experience wasting and undernutrition, while the prevalence of obesity and other chronic diseases has increased significantly. Improved understanding of HIV infection's impact on metabolism and chronic inflammation has only increased the complexity of managing chronic HIV infection. Nutrition assessment should encompass food insecurity risk, changes in body composition, biochemical indices, and clinical indicators of comorbid disease. Side effects from current antiretroviral therapy regimens are less prevalent than with previous generations of therapy. However, micronutrient deficiencies and chronic anemia also remain significant nutritional risks for PLWHA, making vitamin and mineral supplementation necessary in cases of acute deficiency or food insecurity. Additional factors can impact HIV-related nutrition care among the pediatric population, older adults, minority groups, those co-infected with tuberculosis or hepatitis, and PLWHA in rural or underserved areas. Registered dietitian nutritionists and nutrition and dietetic technicians, registered should participate in multidisciplinary care to incorporate nutrition into the medical management of PLWHA.

The impact of nutrition on physiologic changes in persons who have HIV.

HIV affects almost all bodily systems, which can lead to recurrent opportunistic infections, weight loss, distribution of weight changes, and death. Malnutrition and wasting, two symptoms that interfere with nutrient availability, accessibility, and metabolism, are associated with higher morbidity and mortality. Nausea, vomiting, swallowing or chewing difficulties, or the response of the body to opportunistic infections or medications that are considered vital to the treatment of the disease may affect nutritional status. A positive nutritional balance may help to improve the immune and other body systems, and delay the progression of the disease, This article reviews the effect of the nutritional status on the physiologic changes in the person who is infected with HIV.

Pathogenesis of HIV-associated heart disease.

As longevity increases in HIV-infected individuals after the introduction of highly active antiretroviral therapy regimens, long-term effects such as cardiovascular disease and, more specifically, symptomatic heart failure are emerging as leading health issues. In the present review article, we discuss HIV-associated cardiovascular disease, focusing on etiopathogenetic mechanisms that may play a role in diagnosis, management, and therapy of HIV-associated heart failure in the highly active antiretroviral therapy era.

Immunopathogenesis of HIV-related heart muscle disease: current perspectives.

As more effective antiretroviral therapies improve survival times, growing numbers of HIV-positive patients are at risk of developing end-organ damage or neoplasia. Heart muscle disease is the most important cardiovascular manifestation of HIV infection and seems set to become increasingly prevalent. This may take the form of either a dilated cardiomyopathy or isolated left or right ventricular dysfunction, is associated with a poor prognosis, and results in symptomatic heart failure in up to 5% of HIV patients. The precise cause of HIV-associated cardiomyopathy remains unclear but is undoubtedly complex, and most probably multifactorial. This report examines our current understanding of the immunopathogenesis of HIV-associated cardiomyopathy.

Ventricular mass and diastolic function in patients infected by the human immunodeficiency virus.

OBJECTIVE: Echocardiographic and Doppler analysis of myocardial mass and diastolic function in patients infected with HIV. DESIGN: Case-control study. SETTING: Tertiary referral centre, Huelva, Spain. PATIENTS: 61 asymptomatic patients with HIV infection and 32 healthy controls. MAIN OUTCOME MEASURES: Time motion, cross sectional, and Doppler echocardiographic studies were performed, and left ventricular mass and diastolic function variables determined (peak velocity of early and late mitral outflow and isovolumic relaxation time). RESULTS: Left ventricular mass index (LVMI) was decreased in patients compared with healthy controls (mean (SD): 76.7 (23.6) v 118.8 (23.5) g/m(2), p < 0.001). Linear regression analysis showed a correlation between LVMI and brachial fat and muscle areas. The ratio of peak velocities of early and late mitral outflow was decreased in HIV infected patients compared with controls (1.19 (0.44) v 1.58 (0.38), p < 0.001). This ratio was exclusively related to haemodynamic variables (heart rate, systolic and diastolic blood pressures). HIV infected patients had a prolonged isovolumic relaxation time (103.0 (10.5) v 72.9 (12.9) ms, p < 0.001). Isovolumic relaxation time was correlated only with brachial muscle area on multivariate analysis. CONCLUSIONS: HIV infected patients had a reduced left ventricular mass index and diastolic functional abnormalities. These cardiac abnormalities are predominantly related to nutritional status.

Aspects of gastrointestinal immunology and nutrition in human immunodeficiency virus-1 infection in Brazil.

Mucosal surfaces have a fundamental participation in many aspects of the human immunodeficiency virus (HIV) infection pathogenesis. In Brazilian HIV-1 infected subjects, loss of weight and appetite are among the most debilitating symptoms. In this review we describe a defined mucosal immunogen that has profound but transient effects on HIV viral load, and we suggest that gut associated lymphoid tissue under constant immunostimulation is likely to provide a major contribution to the total levels of HIV. We also show that hypermetabolism appears to play a role in the wasting process in Brazilian patients coinfected with HIV and tuberculosis.

Microbiological understandings and mysteries of noma (cancrum oris).

The microbiologic history of noma was reviewed. Studies have associated the disease process with large numbers of fusiform bacilli and spirochetal organisms. In order to study the microbiology of the staging and infection periods of noma 62 Nigerian children, aged 3-14 years, 22 children had acute necrotizing ulcerative gingivitis (ANUG) and were also malnourished, 20 exhibited no acute necrotizing ulcerative gingivitis but were malnourished and 20 were free of acute necrotizing ulcerative gingivitis and in good nutritional state) were evaluated for the presence of viruses and oral microorganisms. The ANUG cases in the malnourished children had a higher incidence of Herpesviridae, the main virus being detected was cytomegalovirus. There were more anaerobic microorganisms recovered, with Prevotella intermedia as the predominant isolate, in the malnourished children as compared to the healthy children. A study of the predominant microflora in active sites of noma lesions was carried out in eight noma patients, 3-15 years of age, in Sokoto State, northwestern Nigeria. Fusobacterium necrophorum was recovered from 87.5% of the noma lesions. Oral microorganisms isolated included Prevotella intermedia, alpha-hemolytic streptococci and Actinomyces spp. which were isolated from 75.0, 50.0 and 37.5% of the patients, respectively. Peptostreptococcus micros, Veillonella parvula, Staphylococcus aureus and Pseudomonas spp. were each recovered from one lesion. All strains were observed to be sensitive to all of the antibiotics tested with the exception of one strain of P. intermedia which showed resistance to penicillin. The pathogenic mechanisms of F. necrophorum as a trigger organism were discussed. The isolation from human noma lesions of F. necrophorum, a pathogen primarily associated with animal diseases, may have important etiologic and animal transmission implications.

Minimizing HIV/AIDS malnutrition.

HIV/AIDS malnutrition influences immune function, disease progression, and quality of life. Changes in dietary intake, altered metabolism, and malabsorption are among the mechanisms that contribute to the nutritional alterations seen in HIV/AIDS. Medical-surgical nurses can help their patients minimize HIV/AIDS malnutrition through early and ongoing assessment, which guides nutritional and pharmacologic interventions.

Malnutrition associated with HIV/AIDS. Part One: Definition and scope, epidemiology, and pathophysiology.

A documented association exists between nutritional status and immunologic function, development, and outcome of infectious processes, and treatment-related toxicity and vital organ function. In persons with AIDS, nutritional deficits precipitate a cycle that results in a downward spiral of weight lost, malabsorption, diarrhea, anorexia, body image disturbance, and increased risk for morbidity and mortality. This article presents an overview of the malnutrition in HIV/AIDS patients. It critiques the current Centers for Disease Control's definitions of wasting syndrome, describes the incidence of weight loss, delineates the implications of untreated malnutrition, and traces the etiology of weight loss and contributing factors. This article serves as an introduction to HIV/AIDS related malnutrition. A subsequent article will review nursing implications and clinical management programs.

Impact of the human immunodeficiency virus type-1 on common pediatric illnesses in Zambia.

The seroprevalence of HIV-1 and in-patient mortality in children with common pediatric illnesses was studied. Between October 1990 and July 1991 at the Department of Paediatrics and Child Health, University Teaching Hospital (UTH), Lusaka, Zambia, mothers of all pediatric admissions were interviewed and counselled for enrollment of their children into the study. Of a total of 1323 children seen, 1266 children (600 female and 666 male) were enrolled into the study. Pneumonia (28 per cent), malaria (24 per cent), malnutrition (18 per cent), and diarrhoea (10 per cent) constituted over 80 per cent of the total admission diagnoses. Tuberculosis (5 per cent) was the fifth commonest cause of admission (61 out of 1266 children). A total of 354 out of the 1266 (28 per cent) children were found to be seropositive for HIV-1 compared to a seroprevalence rate of 9 per cent in children attending accident and emergency for traumatic injuries (P=0.001). High HIV-1 seroprevalence rates were found in children with tuberculosis (69 per cent), malnutrition (41 per cent), pneumonia (28 per cent). and diarrhoea (24 per cent). The overall mortality in hospital among HIV-seropositive children (19 per cent) was significantly higher than those who were HIV-seronegative (9 per cent) (P = < 0.0001).

A review of mechanisms of wasting in HIV disease.

According to estimates, between 50% to 90% of patients infected with the Human Immunodeficiency Virus (HIV) will experience some form of malnutrition. The degree and types of malnutrition are attributed to alterations in nutrient intake, absorption, and metabolism. Causes for each of these changes are complex and multifactorial. Research on treatment modalities generally concentrates on a single mechanism and reports varying degrees of short-term benefit. Appetite stimulation along with special diets, oral supplements, and nonvolitional enteral or parenteral nutrient provision may improve nutrient intake and body weight. Therapies aimed at the rehabilitation and improvement of the pool of functioning protein stores, such as alteration of inflammatory response, restoration of hormonal balance, and exercise are under investigation. Longer term studies will allow researchers to observe effects of therapies on overall body functions. With the development of clinical standards of care, the maintenance and restoration of nutritional status is emerging as the foundation for HIV disease management.

Clinical features of HIV seropositive Zambian subjects.

Data was collected from 1595 anti-HIV positive patients out of which 90% of the patients were from the Copperbelt province, and the rest from five out of the eight other provinces of Zambia. One-hundred and one positive HIV patients were less than 2 years of age, 69 were aged 2 to 14 years and 1418 were aged above 15 years. The male to female ratio was about 1:1 at all ages, except that there was an excess of males below 5 years. Of the four most frequent symptoms or signs, loss of weight or malnutrition was regarded in about 50% of seropositive patients at all ages; generalized lymphadenopathy was seen in at least 35% of all age groups and most frequently at 2-14 (60%); chronic watery diarrhoea was most common at less than 2 years (44%) and least common in older children (17%); chronic chest infections had highest frequency in children 2-14 years (59%) and lowest in adults (32%). Intensive education of children before they are sexually active is the best hope for controlling the epidemic.

PIP: During December 1985 to November 1986, in Zambia, clinicians provided information on 1595 HIV-positive patients to assess the age and sex distribution and clinical features of HIV-positive patients. 92.2% of the HIV-positive patients were from the Copper Province, especially the towns of Ndola (44.9%) and Kitwe (28.9%). 101 HIV-positive patients were under 2 years old, 69 were aged 2-14 years, and 1418 were 15 years old or older. The most common clinical features of HIV infection in all age groups were weight loss/malnutrition (about 50%) and generalized lymphadenopathy (35.1%). They were malnutrition (56.5%), chronic chest infection (48.2%), chronic diarrhea (43.5%), and generalized lymphadenopathy (43.5%) for children aged under 2; generalized lymphadenopathy (60.3%), chronic chest infection (58.6%), weight loss/malnutrition (55.2%), and chronic diarrhea (17.2%) for children aged 2-14; and weight loss (49.3%), generalized lymphadenopathy (33.4%), chronic chest infection (32.3%), chronic diarrhea (29.6%), herpes zoster (14.7%), and sexually transmitted diseases (10.6%) for people aged 15 and older. Generalized lymphadenopathy was significantly more common in the 2-14 year old group than the older age group (60.3% vs. 33.4%; p 0.05). People aged 15 and over were significantly less likely to have chronic chest infection than the other age groups (32.3% vs. 48.2-58.6%; p 0.05). The male/female ratio was 1:0.93 in the 15 and older age group. Solid education of school-aged children before they become sexually active provides the best hope for controlling the HIV/AIDS epidemic in Zambia.