HIV & AIDS

Lisa BullardShannon Rohall

Outline

• Background Information/MNT– Epidemiology– Pathophysiology– Diagnosis– Clinical Manifestations– Treatment– Research supporting MNT

• Terry’s Story • Nutrition Care Process

– ADIM/E

Epidemiology- U.S.A.

• Prevalence: roughly 1 million with HIV & AIDS

Race/ethnicity of persons living with HIV, 2003

                                                                                                                       

                                                                                                 

http://www.cdc.gov/hiv/topics/surveillance/united_states.htm

Epidemiology- U.S.A.

• Incidence:– 40,000 new cases

each year• Majority of new

infections affect:– Minorities– Women– Youth w/ little access

to healthcare (Center for Disease

Control and Prevention, 2005)

Race/ethnicity of personswith a new HIV diagnosis in 2006

                                                                                                                                                                                                                        

http://www.cdc.gov/hiv/topics/surveillance/united_states.htm

Background Information- Etiology

• What is HIV?– Human Immunodeficiency Virus is a

retrovirus.• Targets GI, organ, and immune cells

(specifically CD4 cells, “T helper”)

• What is AIDS?– Acquired Immunodeficiency Syndrome is

“an immune dysfunction characterized by the destruction of immune cells, leaving the body open to infection” (Nelms, et al. 2008).

Pathophysiology

• Figure 26.1 HIV Lifecycle (Nelms et al. 2008)

Pathophysiology

• ↑ viral load ↓ CD4 cells strong relationship to progression to diagnosis of AIDS

• ↓ CD4 cells ↑ opportunistic infection ↓ nutrition status and ↑ mortality http://

hivtreatmentispower.com/images/immune-system-hiv.jpg

Pathophysiology

• When GI cells infected (part of immune defense), ↑ risk of malabsorption– Contributes to

wasting

AIDS-related wasting syndrome

http://student.bmj.com/issues/02/12/education/images/view_1.jpg

Pathophysiology

• Breakdown of protein stores– Protein turnover rate higher throughout

infection– Dysregulation of inflammation response

changes in hormone/nutrient metabolism ↑ risk of chronic ds

Micronutrient Changes

• Lower levels of:– Selenium*– Zinc*– Magnesium– Calcium– Iron*– Manganese– Copper*– Carotene– Choline– Glutathione– Vit A*– Vit B6*– Vit B12* (neurological

changes, bone marrow toxicity, and accelerated progression of HIV)

– Vit E (oxidative stress)

•Elevated levels of:-Folate*-Niacin-Carnitine

* Closely tied to immune fx (Nelms, et al. 2008)

Diagnostic Criteria

Classification Categories Sample Criteria

CD4 + count categories

Category 1 ≥ 500 cells/μL

Category 2 200 – 499 cells/μL

Category 3 < 200 cells/μL

Clinical Categories

Category A Primarily asymptomatic

Category B Symptomatic attributed to HIV infection – fungal, oral hairy leukoplakia, listeriosis, peripheral neuropathy, persistent fever/diarrhea

Category C Diseases that are opportunistic and define AIDS. Cancers, Kaposi’s sarcoma, wasting syndrome, pervasive candidiasis.

CDC Clinical and Immune Cell Categories of HIV Infection

Diagnostic Criteria

Table 26.2 WHO Clinical and Immune Cell Categories of HIV/AIDS Infection

Broken down into classifications set forth by WHO: presence of opportunistic infection and unintentional wt loss (Nelms et al., 2008)

Categories Sample CriteriaPrimary HIV Infection

Acute retroviral syndrome, but no complicating opportunistic infection or immune dysfunction

Clinical Stage 1 Primarily asymptomatic as above, possible persistent generalized lymphadenopathy

Clinical Stage 2 Wt losses that are <10% of body wt, minor mucocutaneous manifestations, recurrent bacterial and upper respiratory infections, fungal infections of fingers

Clinical Stage 3 Wt loss of >10% of body wt, persistent constitutional symptoms (fever, diarrhea), oral thrush or hairy leukoplakia, pulmonary tuberculosis, severe bacterial infections, unexplained anemia, neutropenia, &/or thrombocytopenia for more than a month (confirmatory testing required for anemias)

Clinical Stage 4 HIV wasting syndrome (>10% wt loss w/ chronic diarrhea, weakness, fever), opportunistic events as described in Clinical Category 3

Clinical Manifestations• Neurological disorders

common w/ HIV and treatment

• Loss of ability to perform ADL’s

• Pulmonary disorders may result in inability to maintain adequate food intake

• HIV infected pt at higher risk of cardiac ds

• Hepatic ds• Anemias common in

symptomatic phases• Renal failure• Oral lesions and food

intake

Oral Candidiasis (Thrush)

www.research.bidmc.harvard.edu/.../38_240.jpg

Treatments

• Antiretroviral medication

Multidisciplinary approach!!

• Modulation of altered hormonal environment• Prevention/treatment for opportunistic events• Maintenance and restoration for nutritional status (Nelms et al. 2008)

http://cache.daylife.com/imageserve/04MS19v34822G/610x.jpg

Treatment

• While effective, med cocktail makes pt very ill– Diarrhea– N/V– Appetite loss– Abdominal pain– Taste change– Lipid alterations– Glucose intolerance– Lipodystrophy

• Adherence to medications 20-50% due to side effects of drugs– Requires 95% adherence for effectiveness

(Nelms et al. 2008) http://www.nature.com/nrd/journal/v2/n8/thumbs/nrd1151-f2.jpg

Medical Nutrition Therapy

• MNT goal: support immune fx– Kcal requirements: ↑ 10%-15% (Grunfeld, et al.,

1992)• ↑ REE vs healthy controls (E.A.L. summary- Grade II)

– Protein Requirements- Adequate intake to:• maintain nitrogen balance• maintain normal albumin/prealbumin• prevent wasting• Counteract some meds ↓ muscular protein synthesis• General recommendation: 1.6-1.8 g/kg of current body

weight (McDermott, et al., 2003) if wasted.

MNT, continued

• Fat Requirements– Amount and types based

on:• Energy needs• Cardiovascular risk (high risk

pt.)• Inflammatory condition (oral

thrush)

• Fiber – Similar to healthy controls:

• May improve glu tolerance• Reduce potential

cardiovascular risk and altered fat deposition (ie, lipodystrophy)

http://diabetestotalcontrol.com/images/fats_visible_in_combi.jpg

Medical Nutrition Therapy

• Cause: - Malabsorption

- Oral symptoms/

trouble swallowing

- Certain medications

- Inflammation

- Lipodystrophy

• Implications: - Risk of developing AIDS

• Viral load

Weight Loss:

Pt: Terry Long

• 32 y/o African American male• Chief Complaint:

– Feels exhausted all the time– Sore mouth and throat– Lost wt

• Medical Diagnosis: HIV 4 yrs ago– Not treated previously– Re-diagnosed with AIDS Clinical Category C2,

with oral thrush• SES:

– Bachelors degree, employed as dialysis nurse– Moved in w/ parents d/t unemployment and

inability to care for self– Purchasing/preparation of meals done by parents

and pt

http://tacomaconfidential.typepad.com/.a/6a00d8341d651053ef0105356d2291970b-120wi

Assessment: Lab Values

Lab Value Terry’s value Normal ExplanationPrealbumin 15 L 16-35 Acute catabolism,

inflammation, malnutrition

Bilirubin ↑ 0.9 mg/dL ≤0.3 Prolonged fasting

HDL-C ↓ 42 mg/dL >45 Starvation

Viral Load ↑ 29,000mm3 0

T cells ↓ 255 mm3 800-2500

T helper (CD4+)

↓ 153mm3 600-1500

T suppressor ↓ 102 mm3 300-1000

Assessment: Physical Exam

• Thin appearance• HR: 92 bpm• BP: 120/84 mm Hg• Skin warm and dry w/ flaky

patches– May indicate malabsorption

• Rhonchi in lower left lung– Rattling sounds caused my

mucosal secretions– May indicate pneumonia

• Hyperactive bowel sounds– May indicate bowel necrosis or

infectious enteritis• http://www.nlm.nih.gov/

medlineplus/ency/article/003137.htm

http://www.thaipedlung.org/images/shortcase/board36_1.gif

Assessment: Anthropometrics

• BMI = 20 (19.9)– Below 20 associated w/ ↑ risk for mortality (Nelms et al.

2008)• IBW = 184 lb ± 10% = 166-202 lb

– %IBW: 82% = mildly depleted energy stores• UBW = 160-165 lb

– %UBW = 93%• MAC: 25.4 cm

– Normal: ~ 37cm• % body fat: 12.5%• TSF: 0.7cm 23 %ile

– Normal: 1.07 cm• cAMA (midarm muscle area) = 32.84 cm²

– Interpretation: <5th percentile: wasted

Assessment: Diet-Drug Interactions

• Indinavir: antiviral protease inhibitor– No grapefruit / grapefruit juice– Adequate hydration needed– Taste changes, N/V, regurgitation, abdominal pain, diarrhea– ↑ glucose, ↑ bilirubin, ↑ amylase– Headaches, ascites, kidney stones, insomnia, back or flank

pain, weakness, rare diabetes• Stavudine: antiviral

– Anorexia, ↓ wt– Stomatitis, N/V, abdominal pain, diarrhea– Peripheral neuropathy, chills/fever, headache, weakness,

muscle pain, dementia, insomnia, rash, pancreatitis– Limit alcohol consumption– ↑ bilirubin, ↑ amylase, ↑ lipase, anemia, ↓ platelets, ↓

neutrophils

Assessment: Diet-Drug Interactions

• Didanosine: antiviral– Anorexia, ↓ wt– Dry mouth, stomatitis, ↓ taste acuity, dyspepsia, N/V, pain,

diarrhea, constipation, flatulence– Avoid alcohol– Pancreatitis, peripheral neuropathy, headache, weakness,

insomnia, rash, arthritis, pain, dizziness, congestion, chills/fever, blurred vision, cough, confusion, anxiety, edema, ↑ BP, seizures

– ↑ bilirubin, ↑ alk phos, ↑ uric acid, ↑ amylase, ↑ lipase, ↑ TG, ↑ CPK, ↓ K

• Fluconazole: antifungal (oral candidasis)– Taste changes, dry mouth, N/V, abdominal pain, diarrhea– Hypoglycemia, headache, rash, tremor, ↑ sweating,

hepatotoxicity– ↑ alk phos, ↑ bilirubin

Assessment: Herb-Drug Interactions

• Echinacea: may inhibit metabolism of indinavir (Cyt P-450)

• St. John’s Wort: contraindicated with use of protease inhibitors (indinavir) (Nelms et al. 2008)

http://www.global-b2b-network.com/direct/dbimage/50070102/Echinacea_Root_Powder_Extract.jpg

http://graphics8.nytimes.com/images/2007/08/01/health/adam/19306.jpg

Assessment: Diet Hx

Usual Intake:• Breakfast/lunch

– cold cereal 1-2 C w/ ½ C whole milk• Supper

– Meat: pork chops or other meat, except beef– Mashed potatoes, rice, or pasta, 1 C w/ tea or soda

• Snacks:– Pizza, candy bar, or cookies w/ tea or soda– 1-2 beers or glasses wine several x per week

Food allergies:– Little milk at a time

Dislikes:– beef, coffee, and vegetables (except salad)

Assessment: Intake

24 hr recall:• Sips of applejuice• Pudding, 1 C• Rice and gravy, 1 C• Iced tea w/ sugar

– Sips throughout day

Diet Analysis:•672 kcals•Fat: 16%•Protein: 7%•Fiber: 4 g•Fluids: inadequate

Calories needed with H-B equation: 3099 kcals (AF: 1.2, IF: 1.5)

Diagnosis

• Inadequate oral food / beverage intake (NI-2.1) related to oral thrush and reduced appetite as evidenced by 9-14 lb wt loss, TSF in 23%ile, and 24-hr recall.

Intervention

• Modify distribution, type, or amount of food and nutrients within meals or at specified time (ND-1).

• ↑ calorie, ↑ protein: ~3100 kcals• Avoid grapefruit / grapefruit juice

• Supplemental feeding: Ensure• Multivitamin

Intervention

• Nutrition education and counseling (Fitch, et al., 2006)– Weight maintenance– Drug-nutrient interactions– Other nutritional conditions: hyperlipidemia, family

hx of HTN & CAD– Herbs:

• Ginseng: ↑ BP• Vit C: RDA in comparison to dose currently taking• Milk thistle: laxative effect, upset stomach, diarrhea,

bloating – pros & cons

Intervention

• Action goals– Eat two more snacks each day– Drink one Ensure/day– Increase fluids

• Outcome goals– Short term:

1. stop wt loss by ↑ caloric intake2. Slowly introduce more food as thrush is treated3. Increase fluid consumption

– Long term:1. wt gain back to UBW2. ↑ fruit, veg, dairy (lactose reduced), protein, and fiber intake3. ↑ intake of unsat fat and ↓ sat fat4. Protein store maintenance5. Regular physical activity (aerobic and resistance)

Monitor / Evaluate

• Check in w/ pt daily to monitor tolerance and intake

• Offer services for post – DC.• Possible referral to social worker for

resources.

References

• CDC: HIV and AIDS in the United States: A Picture of Today’s Epidemic. 2005. http://www.cdc.gov/hiv/topics/surveillance/united_states.htm.Accessed April 8, 2009.

• Nelms, et al. “Nutrition Therapy and Pathophysiology”. Belmont: Thompson Corp. 2008.

• Cunningham-Rundles, McNeely, and Moon. 2005.• Fitch KV, Anderson EJ, Hubbard JL, Carpenter SJ, Waddell WR,

Caliendo AM, Grinspoon SK. “Effects of a lifestyle modification program in HIV-infected individuals with the metabolic syndrome”. AIDS. 2006; 20: 1843-1850

• C Grunfeld, M Pang, L Shimizu, JK Shigenaga, P Jensen, and KR Feingold. “Resting energy expenditure, caloric intake, and short-term weight change in human immunodeficiency virus infection and the acquired immunodeficiency syndrome”. Am. J. Clinical Nutrition, Feb 1992; 55: 455 – 460.

• McDermott AY, et al.: Nutrition treatment for HIV wasting: a prescription for food as medicine, Nutr Clin Pract 18:86, 2003.