HIV and Nutritional Knowledge
Prior to the introduction of the HAART in the mid-1990s, the primary nutritional counselling
goal for PLWHA focussed on specific strategies used to manage weight loss and wasting.
But afterwards, nutritional changes in the management of PLWHA meant living healthier,
longer, and more productive lives (Hendrick, Dong, & Gerrior, 2009). This underscores the
importance of providing good and adequate nutrition to infected persons since HIV is
associated with altered nutrient intake, mal-absorption, and metabolic changes.
The other factors associated with inadequate food intake include access to foods, depression,
anorexia, dysgeusia, and dysphagia, (Hendrick, Dong, & Gerrior, 2009). In addition,
evidence from past studies shows that using nutritional interventions that include both food-
based and micronutrient supplementation have some advantages as well as disadvantages
(Rawat, McCoy, & Kadiyala, 2013). In this section therefore, the study reviews literature
related to ways of managing nutritional deficiencies among PLWHA.
Research evidence shows that HIV affects not only the nutritional status by increasing
energy demands, but also reduces food intake and adversely affects food absorption as
well as metabolism (WHO, 2003). The failure to satisfy the nutritional requirements for
HIV infected persons is likely to lead to decreased immunity and increased vulnerability
to opportunistic infections (OIs), resulting in malnutrition. Receiving adequate nutritional
foods is likely to improve absorption and tolerance to antiretroviral by an infected person
(Maertens, 2011), thus, helping improve the quality of life for PLWHA (Anand, Puri, &
Mathew, 2012).
On the contrary, poor nutritional status is a recipe for not only speeding up disease
progression, but also increasing disease incidence and mortality (Hsu, Pencharz, Macallan,
&Tomkins, 2005). For these reasons, it
is becoming increasingly clear that in order to
make a holistic approach to HIV and AIDS, a
fundamental part of it must be nutritional
support. This is why WHO requires care givers
to ensure that the micronutrients needed by
HIV infected persons are met through
increasing access to a diversified diet, fortified
foods,
and micronutrient supplementation, particularly, where deficiencies are endemic (Hsu,
Pencharz, Macallan, & Tomkins, 2005).
Research indicates that food insecurity is related to HIV and AIDS in a unique way. As
one condition increases, it worsens the other condition’s vulnerability and severity. In this
study, food insecurity is understood to refer to a condition where there is either a physical
lack or lack of economic access to sufficient food to be productive and healthy (Anema et
al., 2009). This is because food insecurity among PLWHA is related to decreased CD4
cells, increased OIs, hospitalizations, and deaths (Palermo, Rawat, Weiser, & Kadiyala,
2013). However, research evidence has shown that good nutrition offers hope to people
infected with HIV by increasing resistance to infection, helping maintain weight as well
as improving the quality of life, and increasing drug compliance and efficacy (Palermo,
Rawat, Weiser, & Kadiyala, 2013).
Since the emerging of HIV; there have been growing suspicions that improved nutritional
status might have a positive impact on the disease progression (Hughes & Kelly, 2006)
for the reason that HIV impairs the immune function and independently affects the
immune system (Chandra, 2002). This has made studying the impact of nutrition among
PLWHA challenging. Among the challenges, the more important ones include a
heterogeneous patient population that makes it difficult to determine nutrient doses and
combinations and, lack of deficiency baseline levels as well as study endpoints.
In their article on reviewing nutrition and disease progression, Chandrasekhar and Gupta
(2011) reviewed 31 clinical trials and found few micro and macro nutrient
supplementations that improve CD4 cell count or decrease viral load. Even if that be the
case, nutrition and exercise on their own play a vital role in the overall care and treatment
strategy for PLWHA (Raiten, 2011; Raiten, Mulligan, Papathakis, & Wanke, 2011).
Going by earlier studies, HIV-related weight loss and wasting is driven by increased
energy demands against low energy intake resulting from HIV and related infections. To
function well, experts in nutrition belief that the energy requirements for people infected
with HIV needs to be boosted by about 10% over the accepted levels required by the
otherwise healthy persons. The basis for this recommendation is the observed increase in
resting energy expenditure required by HIV-infected adults (WHO, 2003). During illness,
PLWHA are likely to suffer loss of muscles, and subcutaneous fat also known as fat
hypertrophy. However, the loss may either be or may not be reflected in the person’s total
body weight, thereby demanding for regular assessment of both the weight and fat
composition of the body. In this way, it might be possible to detect any structural changes
in the loss, accumulation, or changed distribution of fat as well as the AIDS wasting
syndrome early enough to enable one start treatment.
Other manifestations due to HIV infection and AIDS are hematologic abnormalities which
may lead to indirect effects of the infection. The most common of these manifestations
include anaemia, adverse reactions to medications, OIs, and nutritional mal-absorption or
metabolic disorders which have a daily bearing on the quality of life. Symptoms for the
resultant anaemia include loss of vigour, rapid heartbeat, and shortness of breath making
anaemia an independent risk factor for early death in AIDS patients (Mocroft et al., 1999).
Therefore, given that anaemia is prevalent amongst PLWHA, eating a wide variety of
nutritious foods rich in iron is suspected to be by far the most cost effective prevention
method. This is premised on research evidence that found out that when nutritional
supplements are taken concurrently with ARTs they improve haemoglobin, and both red
and white blood cell count (Houtzager, 2009).
According to NASCOP (2011), a person diagnosed with HIV at stage one (free of AIDS
related symptoms) requires 10% more energy than demanded by healthy individuals. But,
the individual requires 20-30% more energy if the disease progresses to stage 2, 3 and 4
(AIDS related symptoms having emerged). Additionally, Bhatt et al. (2015), assert that
the quantity and type of nutrients to be taken is dictated by the health status of an
individual. For example, a healthy adult requires approximately 2070 kcal/day of energy
including about 57 grams/day of protein. But for an infected adult, the requirement
increases by 10-15% more energy and approximately 50-100% more protein compared to
a healthy adult. These foods should also be rich in vitamins since infected persons are
vulnerable and hence need adequate protein, fat, vitamins, trace elements/minerals
(micronutrients) and water always. NASCOP (2011) posits that inadequate intake of
energy and other nutrients leads to malnutrition and wasting. The situation is worsened
by PLWHA living in food insecurity settings.
In their research, Mihan, Kerr, Maticka-Tyndale, & ACBY Team (2016) found that lack
of some specific micronutrients in the body is likely to create a conducive environment
for the duplication of the virus. Furthermore, although antioxidants are good at inhibiting
HIV replication, they however promote OIs by preventing the oxidative burst associated
with the bactericidal properties of phagocytes (Thomas, Bosche, Shatzer, Johnson, &
Gorelick, 2008).
Although the prevalence of anaemia in Africa is estimated at 46%, the prevalence rates
among persons infected with HIV are elevated and estimated at between 70-80%
(Chatterjee et al., 2010). With time, there is further decline in CD4 cells by about 50%
becoming one of the main factors causing high death rates among HIV infected
individuals. A study conducted by Vishnu and Aboulafia (2015) found out that the major
causes of anaemia among PLWHA were bone marrow infections and neoplasm.
According to Fang and Aboulafia (2016), increased destruction, loss, and impaired
production of red blood cells are the three main causes responsible for anaemia in
PLWHA. Anaemia is usually classified based on the size of the red blood cells. The three
major types per this classification are microcytic, normocytic and macrocytic. The major
cause of microcytic anaemia (where the red blood cells are smaller than normal) is the
inherited haemoglobin disorders. But, the second type – normocytic anaemia (where the
red blood cells are normal in size but low in number) is a condition associated with
chronic diseases. The last type – macrocytic anaemia (where the red blood cells are larger
than normal) is a condition associated with alcoholism.
On their part, Butensky, Kennedy, Lee, Harmatz, and Miaskowski (2004) noted that the
influence of changed iron metabolism is due to the effects of HIV enabling viral record via
the initiation of oxidative stress, secondary to chemical reactions. This reaction enhances the
replication of HIV in macrophages as well as onlooker lymphocytes. In addition, anaemia in
PLWHA can be attributed to OIs, medication, and mala-absorption of both vitamins and trace
elements. In other words, in a majority of the cases, anaemia is treatable.
Firnhaber et al., (2010) observe that currently there are a variety of methods in use in the
treatment of iron deficiency anaemia. The main ones include iron supplementation, blood
transfusion, ARTs, as well as dietary intervention. But, most of these methods are
plagued with adverse side effects which may affect the health outcomes of the infected
negatively. Although transfusing an anaemic patient with blood corrects low red blood
cell count, it does not however, correct the underlying cause, especially if insufficient
volume of blood is administered to patients.
Although a study conducted in Siaya District observed the benefits of blood transfusion
among anaemic women (Zucker et al., 1997), another later study questioned the safety of the
approach (Moore et al., 2001). It estimated a 6.4% risk of contracting HIV through blood
transfusion due to poor record keeping and transcription errors, inability to interpret results,
pipetting errors, and lack of a quality assurance program. In conclusion, the study noted that
poor laboratory practices were to blame for increased HIV prevalence. Therefore, the most
frequently used treatment to correct iron deficiency anaemia is iron supplementation. But,
some researchers doubt the efficacy of using iron supplementation. In fact, iron
supplementation has been reported to have adverse effects on PLWHA (Alleyne, Horne, &
Miller, 2008). Excess iron in the body is detrimental since it serves as a nutrient to the host
cell thus assisting viral infection (Tsay et al., 2010).
With the introduction of HAART, the management of HIV has remarkably improved thus,
leading to a significant decline in OIs. The position is supported by evidence derived from a
study by Moore and Forney (2002) who conducted a study aimed at ascertaining the
relationship and impact of HAART on anaemia and survival of women living with HIV.
The study found the treatment to be effective, however, women who continued to be
anaemic, needed additional intervention.
Given the adverse effects of drug therapy and blood transfusion and the cost implication
especially in poorly resourced countries, the treatment is way out of reach by the needy.
As a result, dietary interventions present a safer and more affordable alternative.
However, for the intervention to be successful, education is required to improve the
nutritional knowledge and practices to support positive health outcomes (Tsay et al.,
2010). A survey conducted by Kisingu et al., (2016) in conjunction with Kenya Medical
Research Institute and JKUAT found out that to attain acceptable levels of nutrition
intake among adults, cereals and vegetables were the most consumed, but there was low
consumption of iron-rich foods across the groups that were surveyed during that time.
This finding is a significant pointer to the need for nutrition education since many adults
living with HIV are becoming obese.
Apart from anaemia, other complications resulting from HIV infection include diarrhoea
and mal-absorption. However, these can also result from direct infection in the intestine.
But, more often, they are caused by other pathogens that take advantage of the poor
immune system. Equally, medication can interfere with eating. Socioeconomic factors
also play an important role on whether the patient can afford adequate and nutritious
food. This is where cheap traditional locally available foods rich in iron can become
useful. These foods do not have side effects and absorption problems.
From a nutritional standpoint, there is hardly any study that has investigated locally available
foods that can supply cheap but with a high percentage of minerals and nutrients-cereals for
energy and vegetables for iron. This study sought to fill the knowledge gap by
assessing society knowledge level in terms of locally available foods that can suitably
supply energy and minerals, in particular, iron.
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