A Wholesome Approach: Nutrition and HIV/AIDS

Adapted from the USAID SARA and FANTA 2 Programs, ECSA-HC, LINKAGES, and PEPFAR

Malnourished children receive a therapeutic milk product at a USAID-funded feeding center in Kalonge, South Kivu, in the Democratic Republic of the Congo. Source: USAID/DRC

Food and nutrition interventions are critical components of a comprehensive response to the HIV/AIDS pandemic. As the virus continues to grow and shift, particularly in sub-Saharan Africa, communities, service providers, researchers, and donors recognize the need to address nutritional aspects of care. USAID strengthens nutritional care and support for people living with HIV/AIDS (PLWHA), and has produced program guidance on nutritional care and support interventions, the nutrient requirements of PLWHA, and food and nutrition complications of antiretroviral therapy.

Nutritional and Biological Factors Associated with HIV Infection

The effect of HIV on nutrition begins early in the course of the disease, even before an individual may be aware that he or she is infected with the virus. The body needs additional energy and nutrients to replicate the virus, compensate for nutrient losses, and physically battle symptoms such as fever or anemia, which are often present in HIV infection. Over time, PLWHA gradually decrease their physical activity, limiting their capacity to carry out regular daily activities.

As HIV progresses, individuals generally suffer from loss of appetite, nausea, constipation, bloating, and heartburn. Many of these symptoms and more, particularly in combination, make eating a hard prospect. In addition, PLWHA tend to have various oral conditions that can make it even more difficult to chew and swallow food. These conditions include bacterial infections such as gingivitis or periodontal disease, viral infections such as herpes, and fungal infections such as thrush. Oral lesions, which are often associated with HIV infection, require medical treatment, oral hygiene, and proper dietary management. If not addressed, an individual’s food intake can be severely hampered, leading to malnutrition.

Moreover, HIV infection can also reduce the body’s ability to absorb nutrients, further increasing nutrient gaps. This process sets up a vicious cycle, as micronutrient deficiencies contribute to disease progression. For example, deficiencies of vitamins and minerals, such as vitamins A, B-complex, C, E, selenium, and zinc, which are needed by the immune system to fight infection, are common in people living with HIV. Deficiencies of antioxidant vitamins and minerals contribute to oxidative stress, a condition that may accelerate immune cell death and increase the rate of HIV replication.

The Importance of Good Nutrition for PLWHA

In this era of potent antiretroviral therapy (ART), malnutrition has been recognized as a significant problem and correlates directly to mortality for HIV patients. The degree of malnutrition is highest among patients with advanced illness due to decreased intake of quality foods, increased energy requirements, and mal-absorption. As noted, nutritional deficiencies in people living with HIV/AIDS begin early and often go unrecognized. Therefore, optimizing nutritional status is a key objective in comprehensive management of HIV clients. Placing patients on antiretroviral therapy is, in fact, related to improved nutritional status. Though side effects can be severe and negatively affect adherence to antiretroviral drugs (ARVs), patients generally experience a stabilization of their condition and a gradual improvement in health.

In partnership with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), USAID follows PEPFAR guidance on providing nutritional support to the following populations: orphans and vulnerable children born to an HIV-infected parent, HIV-positive pregnant and lactating women in programs to prevent the transmission of HIV to their children, and adult patients in ART and care programs with a body mass index (BMI) of less than 18.5. In a key policy change, PEPFAR updated its policy guidance to allow food support to patients in ART and care programs with a BMI lower than 18.5, replacing the BMI threshold of 16 in the earlier guidance. This revised policy is in line with World Health Organization (WHO) guidance and became effective for PEPFAR programs in fiscal year 2008. Support for supplemental feeding programs ends when the patient’s BMI stabilizes above 18.5 for two consecutive months. USAID and PEPFAR anticipate this policy revision will result in further support for HIV-positive individuals before they reach the point of severe malnutrition, which will help to improve overall health outcomes.

Food as Medicine: The Food by Prescription Program

USAID and other key stakeholders have promoted the use of the Food by Prescription (FBP) program, designed to improve clients’ health and nutritional status and improve adherence to and efficacy of ART. Already under way in several countries, including Kenya, Haiti, Uganda, and Zambia, FBP programs are starting up in Ethiopia and Tanzania. Food by Prescription was first instituted in Kenya and was designed as a time-limited medical intervention for PLWHA meant to halt and reverse the impact of malnutrition on the patient and disease process and progress. Some key characteristics of FBP include:

• Distribution of therapeutic and supplementary foods only to PLWHA
• Use of clear patient entry and exit criteria associated with BMI and nutritional status
• Nutritional counseling
• “Prescribed” amounts of food likened to taking medication

Food products used in FBP are categorized into two groups: therapeutic foods and supplementary foods. These foods must be safe, effective, of consistent high quality, palatable, easy to digest, culturally appropriate, cost effective, and feasible to deliver to clients. They must be simple to prepare without requiring large amounts of water, be nutrient dense, and free of contamination.

Therapeutic foods are prescribed for severely malnourished children and adults at both the health facility and community levels. They include Ready-to-Use Therapeutic Foods (RUTF) and therapeutic milks. RUTF is an energy-dense, mineral- and vitamin-enriched food specifically designed to treat severe acute malnutrition (SAM). It is soft and easier than home foods for severely malnourished children over the age of six months to eat and does not require water. Because it is not water based, bacteria cannot grow in it, and it can be used safely without refrigeration. RUTF has been shown to be effective in nutritional rehabilitation of HIV-positive and HIV-negative children, though it is not as easily consumed by adults due to its extreme sweetness and pasty consistency.

In contrast, supplementary food (i.e., fortified blended food, or FBF) are flour blends made from soy, wheat and/or corn and fortified with nutrients such as calcium and iron. They are prescribed in conjunction with RUTF, as a palatable complement that is compatible with local diets. Fortified blended foods are blended based on cereal-based flours that are fortified with micronutrient premix. Careful attention must be paid in determining fortification levels so that clients who consume both RUTF and fortified blended foods do not receive micronutrient levels that are greater than safe intake levels. FBFs historically come in large packaging. However, the ideal FBF packaging consists of 100-, 200-, or 300-gram sachets because these “doses” discourage sharing and encourage patients to eat the right amounts and view the food as part of their therapy, similar to medicine. This type of packaging also facilitates monitoring of adherence and consumption.

Learn more about how USAID supports nutrition interventions worldwide.

June 2009

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