Consultation on Nutrition and HIVAIDS in Africa

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Consultation on Nutrition and HIV/AIDS in Africa
Evidence, lessons and recommendations for actions

• International Convention Centre (ICC)
• Durban, South Africa
• 10-13 April 2005

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• www.sahims.net

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Where do we stand?

• Sub-Saharan Africa is home to more than 60 of
  all people living with HIV/AIDS.
• Both HIV infection and malnutrition rates are
  rising in the region.
• African governments are urgently facing a range
  of policy and programme challenges related to
  food, nutrition, and scaling-up programmes to
  accelerate access to life-saving antiretroviral
  therapy (ART) and HIV care.

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Consultation on Nutrition and HIV/AIDS in Africa
Evidence, lessons and recommendations for actions
A direct response to Resolution 57.14 of the
World Health Assembly, 22 May 2004 on "Scaling up
treatment and care within a coordinated and
comprehensive response to HIV/AIDS". This
resolution urges Member States as a matter of
priority to pursue policies and practices that
promote integration of nutrition into a
comprehensive response to HIV/AIDS article
2(3)(h).
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The Goal of the consultation is to

• Develop strategies that are both evidence-based
  and feasible to help improve the health status of
  people living with HIV/AIDS in southern and
  eastern African countries.
• Review and disseminate the latest evidence on
  nutrition and HIV/AIDS, and thereby help ensure
  nutrition is integrated as part of a
  comprehensive response to HIV/AIDS.
• Identify a research agenda to fill the critical
  gaps in knowledge.

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The Process, TAG and partners

• Joint NHD/HIV/AIDS Departments effort
• Contributions and partners
• WHO Technical Advisory Group on Nutrition and
  HIV/AIDS
• 230 participants from 20 countries, 6 UN
  agencies, 8 Regional Groups and 21 NGOs - with
  bilaterals, research groups and institutions,
  donors and PLWHA

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Several firsts

• First international consultation convened by WHO
  to bring nutrition and HIV/AIDS people together
  in direct response to the 2004 WHA Resolution.
• A full scientific review of the evidence was
  undertaken to examine the issue from a
  nutritional and lifecycle perspective. All age
  groups and stages of disease were considered. The
  interaction between nutrition and ARV therapy was
  also reviewed.
• Teams of 3 to 4 people coming from 20 countries
  came together to share experiences and plans, and
  to help us identify priority actions and research
  questions.
• A participants Statement put out by WHO and its
  partners in this area to raise and solicit a
  solid commitment. The outcome of the meeting will
  be presented to WHO Executive Board in one month.

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Facts - 1

• The relationship between nutrition and HIV/AIDS
  in complex. HIV progressively damages the immune
  system and malnutrition itself may also increase
  the susceptibility to infection
• Both scenarios can make a person susceptible to a
  range of opportunistic infections and conditions,
  such as weight loss, fever and diarrhea
• These conditions can also lower food intake
  because they both reduce appetite and interfere
  with the body's ability to absorb food
• Evidence suggests that malnourished adults and
  children initiating ART require adequate food to
  support nutritional recovery

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Facts - 2

• As in the general population, a diet that
  provides the full range of essential
  micronutrients is important to the health of
  people living with HIV and AIDS.
• No evidence that food and dietary improvements
  alone can stop people who are infected with HIV
  from progressing to AIDS.
• Comprehensive care for people living with HIV and
  AIDS should include both good nutrition and
  antiretroviral therapy, where clinically
  indicated.

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Scientific review on nutrition and HIV/AIDS

• Micronutrients
• How HIV infection leads to micronutrients
  deficiency, and how deficiencies/supplementation
  may affect various transmission and
  progression-related outcomes
• Macronutrients (Energy and Protein)
• How HIV infection affects energy/protein
  requirements, and how deficiencies/supplementation
  may affect various transmission and
  progression-related outcomes

• Infant feeding and HIV transmission
• Growth faltering and wasting in children
• Maternal Nutrition or pregnant and lactating
  women
• Nutrition and ARVs
• How nutrition may affect ARV efficacy and how
  ARVs may lead to better nutritional status on
  the one hand and dyslipidemia and insulin
  resistance on the other

Summary, conclusions and recommendation (NHD)
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Key Findings of the Review Macronutrients

• Resting energy expenditure rates (REE) are
  increased during HIV infection
• Therefore energy requirements are higher in
  PLWHA
• Asymptomatic there is a 10 increase in kcal/day
  
• Symptomatic there is a 20-30 increase in
  kcal/day
• Children with weight loss there is a 50-100
  increases in kcal/day

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Key Findings of the Review Macronutrients

• There is a common belief that protein
  requirements are increased due to HIV infection
• However, evidence suggests that low energy intake
  combined with increased energy demands of HIV
  infection are the major driving forces behind
  HIV-related weight loss and wasting.
• Although protein metabolism may be affected by
  HIV infection, there is no evidence that
  increasing protein intakes will improve protein
  status or muscle mass.
• Nitrogen balance studies needed
• Therefore, data are insufficient to support an
  increased protein requirement due to HIV
  infection.
• 12-15 of energy intake should come from protein

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Key Findings Micronutrients

• Micronutrient deficiencies are frequently present
  in HIV-infected adults and children.
• Micronutrient intake at RNI levels are
  recommended for HIV-infected children and adults.
  These needs are best met through consumption of
  a diverse diet and fortified foods
• Some studies have shown that micronutrient
  supplements may delay HIV disease progression and
  prevent MTCT.
• However, additional research is needed to confirm
  these results and their generalizability

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Key Findings Pregnant and lactating women

• Pregnancy and lactation do not hasten the
  progression of HIV infection to AIDS.
• HIV infected pregnant women gain less weight and
  experience more frequent micronutrient
  deficiencies
• During lactation the change in weight is greater
  in HIV infected mothers.
• Optimal nutrition of HIV infected mothers during
  pregnancy and lactation increases weight gain,
  and improves pregnancy and birth outcomes.

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Key Findings HIV-infected children

• HIV-infection impairs the growth of children
  early in life. Growth faltering is often
  observed even before the onset of symptomatic HIV
  infection. Poor growth reflects the risk of
  child mortality in HIV-infected children.
• In HIV infected children viral load, chronic
  diarrhoea and other opportunistic infections
  impair growth.
• The growth and survival of HIV-infected children
  is improved by prophylactic cotrimaxozole, ARV
  therapy and the early prevention and treatment of
  opportunistic infections.
• Improved dietary intake enables HIV children to
  regain lost weight after opportunistic infection.

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Key Findings Infant feeding and HIV

• Maternal CD4, blood and BM viral load are
  associated with increased risk of HIV
  transmission during BF
• The risk of HIV transmission during BF
  breastfeeding is constant over time
• New data from Zimbabwe confirm earlier reports
  indicating that risk of breastfeeding-associated
  HIV transmission is increased with early mixed
  breastfeeding compared with early exclusive
  breastfeeding (EBF)
• Data from several studies report that
  education/counseling increase frequency and
  duration of EBF
• No data available on impact of early
  breastfeeding cessation on mortality, HIV-free
  survival

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Nutrition and ARV interactions

• Dietary and nutritional assessment is an
  essential part of comprehensive HIV care both
  before and during ART.
• Long term use of ART can be associated with
  metabolic complications.
• The value of ARV therapy far outweighs the risks.
  However, these metabolic complication must be
  adequately managed, when they occur.
• There is a need to look at interactions between
  nutrition and ARV's in chronically malnourished
  populations.
• The effect of traditional remedies and dietary
  supplements on the safety and efficacy of ARV
  drugs needs to be evaluated.

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Action points

• 1. Conduct advocacy to strengthen political
  commitment and improve the positioning of
  nutrition in national policies and programs
• Use existing advocacy tools, and develop news
  ones, as needed, to sensitize decision-makers
  about the urgency of the problem and impact on
  development targets.
• Such advocacy should be to increase commitment
  and support for improved nutrition, in general,
  and for addressing the nutritional needs of
  HIV-affected and infected populations, in
  particular.

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Action points

• 2. Develop practical nutrition assessment tools
  and guidelines for home, community, health
  facility-based and emergency programmes
• Validate simple tools that can be used by front
  line workers to assess diet, nutritional status,
  and food security so that nutrition support
  provided within HIV programs is appropriate to
  individual needs.
• Develop standard operating procedures to define
  the nutrition actions that should be taken at
  health-facility and community levels and improve
  quality of care (who, what, when, and for how
  long).
• Review and update existing treatment protocols to
  include nutrition/HIV considerations (e.g.,
  integrated management of adult illness, ARV
  treatment, nutrition in emergencies)

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Action points

• 3. Implement at scale existing interventions for
  improving nutrition in the context of HIV.
• Accelerate implementation of the Global Strategy
  for Infant and Young Child Feeding.
• Renew support for the Baby Friendly Hospital
  Initiative.
• Accelerate training and use of guidelines and
  tools for infant feeding counselling and maternal
  nutrition in PMTCT programs.
• Expand access to HIV counselling and testing so
  that individuals can make informed decisions and
  receive appropriate advice and support on
  nutrition, including in emergency settings.
• Implement WHO protocols for vitamin A,
  iron-folate, zinc, multiple micronutrient
  supplementation and management of severe
  malnutrition.

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Action points

• 4. Build a learning environment at all levels,
  through operations research and information
  sharing, to facilitate evidence-based programming
• Develop and implement operations research to
  identify effective interventions and strategies
  for improving nutrition of HIV infected and
  affected adults and children.
• Document results, publish findings in journals,
  and ensure access to lessons learned at all
  levels.

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Action points

• 5. Develop human capacity and skills to ensure
  that nutrition is appropriately implemented in
  HIV prevention, treatment, and care programs
• Include funding for nutrition capacity
  development in HIV scale up plans.
• Incorporate nutrition into training of front line
  health, community and home-based care workers.
  Specific skills such as nutritional assessment
  and counselling, and program monitoring and
  evaluation should be included. Such training
  should be not favour particular commercial
  interests.
• Strengthen the capacity of government and civil
  society to develop and monitor regulatory systems
  to prevent commercial marketing of untested
  diets, remedies, and therapies for HIV-infected
  adults and children.

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Action points

• 6. Incorporate nutrition indicators into HIV/AIDS
  monitoring and evaluation plans
• Include appropriate nutrition process and impact
  indicators for community surveillance, and
  national, regional, and international progress
  reporting.
• Several process and impact indicators proposed.

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