[intaids] Report from AIDS2002 Nutrition and HIV satellite

["INTAIDS" <intaids@healthdev.net>]

Food and Nutrition Insecurity Complicate HIV Care in Developing Countries
Report from the Satellite Conference at XIV World AIDS Conference
***************************************************************

Report Written By Ellen Engelson, EdD for HIV and Hepatitis.com
Dr. Engelson is Associate Director, GI Research and Training, St.
Luke's-Roosevelt Hospital Center, Columbia University, New York City

"The Challenges of Nutrition Care and Support for People Living with
HIV/AIDS in Resource Poor Settings" was organized by Dr.Subhasree
Raghavan, Harlem Hospital & Columbia University, New York and Drs. Ellen
Piwoz of the Academy for Educational Development

AIDS is now in virtually every country in the world, Peter Piot from the
UN told delegates at the opening ceremony of the XIV International AIDS
Conference in Barcelona, Spain (July 7-12, 2002).However, the challenges
and experiences vary from continent to continent, country to country and
city to village. In the poor and developing countries, lack of adequate
food and nutrition significantly complicates the management of HIV/AIDS.

Delegates from the US were often cited as coming from the richest and most
powerful country in the world, and 21 years of disease, advocacy,
scientific and social research have in fact resulted insignificant but
often expensive improvements in treatment options and reductions in
morbidity and mortality in North America and Europe. However, the picture
is vastly different in many parts of the world, particularly in developing
and resource-poor countries.  Some of the major challenges the latter
countries face include those regarding the basic needs of food and
nutrition. These range from lack of food and clean water due to poverty,
war and drought, to lack of knowledge regarding basic nutritional
principles, to cultural gender relationships that keep the best food for
men.  The presence of HIV and AIDS in significant portions of the
population only complicates and worsens matters.

This article will review two sessions from the AIDS conference and make
links between them.  "The Challenges of Nutrition Care and Support for
People Living with HIV/AIDS in Resource Poor Settings" was organized by
Drs. Ellen Piwoz of the Academy for Educational Development and Subha
Raghavan of Harlem Hospital and Columbia University in New York, USA. The
session was held in a room too small for the number of delegates wishing
to attend, and the first speaker thought this invited outrage since 95% of
people infected with HIV throughout the world are malnourished.

Coincidentally in keeping with the conference's theme, Knowledge and
Commitment for Action, this program first provided an overview of the
problem and the scientific background based on research and experiences in
the developed, resource-rich countries, then had speakers who are
committed to the problem present their interventions and experience in
developing countries, and finally reviewed the challenges that remain in
further putting this knowledge and commitment toward action. One of the
major challenges for adequate nutrition is Food Security, and the second
session covered here was "The Challenge of HIV/AIDS on Food Security and
Nutrition."  This was organized by a coalition of non-governmental
organizations who regularly address this issue, specifically the Food and
Agriculture Organization (FAO), the World Food Programme (WFP), the
International Fund for Agricultural Development (IFAD) and the World
Health Organization.  It was the first satellite symposium on this topic
in the 14 international conferences.

Malnutrition and HIV 
To clarify the distinction between food and nutrition, nutritionist Cade
Fields-Gardner noted that the availability of an adequate and varied food
supply is distinct from the nutritional manipulations necessary to address
a specific disease state such as AIDS.  And malnutrition can occur even in
the context of abundant food, as experienced by the first speaker in the
first session, Donald Kotler, MD from New York City.

Between 1981 and 1994, malnutrition was quite common in HIV-infected
individuals in the US. In addition, Dr. Kotler's experience from that
period indicated that many of the consequences of HIV and malnutrition are
similar since malnutrition results in deficient immune responses.  In the
1970's,Dr. Ranjit Chandra, working in southern India first noted that
malnourished individuals had reduced skin reactivity in response to an
immune stimulus, and that post-operative complications including sepsis
and mortality were increased in the same individuals.

Malnutrition and AIDS Wasting
Malnutrition and HIV both result in a spiral of progressive disability.  A
1989 paper from Kotler et al showed that malnutrition due to HIV
negatively impacts survival, but made it clear that the effect of
malnutrition was independent of the effect of any particular opportunistic
infection.  The level of malnutrition related to death was also similar to
the level found in situations of starvation.

Many people think of malnutrition in the context of HIV as AIDS wasting,
but, as defined by the CDC, AIDS wasting may be a conservative measure of
malnutrition. CDC definition contains other factors, but primarily affects
diagnosis as at least 10%unintentional weight loss. In fact, it is
possible to be malnourished with a lesser weight loss if it occurs within
several months. Based on a large database of healthy people, Dr. Kotler's
group determined that 5% is normal variation within 3 months.  However,
weight is often inaccurate as a determinant of nutritional status. During
the first few years of the epidemic, Dr. Kotler often saw people averaging
80% of their ideal body weight, with significant weight loss of 25-30%. 
They also were anemic, hypoalbuminec and protein depleted. When
hospitalized, they gained weight, but this reflected the intravenous
fluids they received rather than a return to healthy nutritional status. 
For this reason, it became clear that body composition measurement is
preferable to weight as an indicator of nutritional status. Body
composition methods vary in complexity and components measured.

In AIDS wasting, it was found that men tend to lose body cell mass while
women tend to lose fat.  (Body cell mass (BCM) is the metabolically active
body compartment, where oxygen is utilized and carbon dioxide and heat are
produced.  It is related to body musculature, which is necessary for
physical functioning.)Causes for the disparity in body composition changes
may be the relative degree of fat a gender tends to have available before
illness to provide energy requirements, or changes in hormonal status,
including hypogonadism - decreased testosterone in men and decreased
estrogen and/or progesterone in women.

In addition to gender differences, malnutrition varies according to stage
of HIV disease, concurrent illnesses and intravenous drug use. In fact,
gender differences are minimized at end-stage illness. Weight loss and
body composition changes tend to be episodic, with increased rates of
depletion during periods of systemic illness when increased energy
expenditure may occur. Some resolution of the malnutrition is possible
during periods of relative health, but lack of weight gain with treatment
of opportunistic infections predicts a poor outcome.  Malnutrition can
also contribute to poor tolerance to therapies for opportunistic
infections.

Starvation and Sepsis 
Dr. Carl Grunfeld, MD from the Veterans Administration Hospital in San
Francisco, California explained further how wasting occurs. An important
concept is the difference between starvation and sepsis. During chronic
food intake deficits or nutrient malabsorption, the body has compensatory
mechanisms for self-protection. Basal metabolic rate and nitrogen
excretion decrease. In contrast, during sepsis (systemic infection) those
compensatory mechanisms do not hold as the body increases basal metabolic
rate (fever) as well as production of acute response proteins in its fight
to destroy the invading pathogen(s).

Although urinary nitrogen loss can be similar in starvation and sepsis,
during starvation, protein deficit can be as low as 20 grams per day as
opposed to approximately95 grams during sepsis. Both starvation and sepsis
can occur in people with HIV, even when food intake appears adequate. Most
studies that measured resting energy expenditure found it elevated,
sometimes associated with secondary opportunistic infections (OIs) and
active ongoing weight loss.

On the other hand, systemic infections can also contribute to decreased
appetite and food intake and/or to decreased intestinal nutrient
absorption.

HIV-Related Ois 
Grunfeld found that people with HIV and OIs lost as much as 5% of their
body weight within 28 days! Compare this with Kotler's finding of 5%
normal variation within 3 months. A paper from Derreck Macallan et al (yr)
showed that when HIV+ people were divided into 3 groups based on rate of
weight loss, 82% of those with acute loss (>4kg within less than 4 months)
had systemic infections, 65% of those with chronic weight loss (>4 kg over
more than 4 months) had gastrointestinal disease, and 83% of those with
weight gain were recovering from an OI. Those with systemic infections are
more likely to show a history of weight loss that is episodic with
significant though not total gains between infections, while those with
untreated GI disease had steadier decline.

Rapid weight loss can also indicate a combination of increased resting
energy expenditure and decreased intake.  Of course, it is the balance of
total energy expenditure and intake that determines weight change. While
food intake decreases in both sepsis and starvation, total energy
expenditure can be adjusted down through decreased physical activity as
often occurs in illness and malnutrition. Both HIV and secondary
(opportunistic) infections contribute to altered metabolism and anorexia,
and it is the failure of compensatory mechanisms that results in negative
energy balance and weight loss, which contributes to further debilitation
and an inability to recover weight and rebuild lean body mass.  With each
episode of illness, weight decreases further and debilitation progresses.

Dr. Grunfeld noted that the take-home message he would like to impart to
the developing world is that rapid weight loss in HIV indicates an
underlying secondary infection that requires treatment.  This of course is
in settings where food availability has not recently declined.

HIV and Macronutrients
Drs. Kotler and Grunfeld focus in their research on the macronutrients,
the protein, fat and carbohydrates that provide calories.  Dr. Marianna
Baum of Florida International University, on the other hand, has spent
many years investigating the relationships between HIV and micronutrients,
i.e., vitamins and minerals which exist in the body in relatively small
amounts and generally have co-enzyme activity, but also include calcium
and phosphorus, the main mineral constituents of bone. Dr. Baum borrowed
the concept of a nutritionally-acquired immune deficiency syndrome (NAIDS)
from WR Beisel (Beisel, WR, Nutr &Immun., ed. Gershwin, German, Keen,
Humana Press, 2000).NAIDS exists with three overlapping contributing
factors: metabolic disorders during relatively asymptomatic periods,
periods of secondary infection or malignancy that contribute to decreased
food intake, and nutrient malabsorption.

In turn, NAIDS impacts the course of HIV/AIDS. Dr. Baum reported that
malnutrition can begin during asymptomatic periods in HIV disease with
metabolic effects, including cytokine-induced hypermetabolism. 
Malnutrition worsens with episodes of infection and malignancy that
decrease food intake and/or result in nutrient malabsorption, including of
fat and fat-soluble vitamins, and can result in a nutritionally acquired
immune deficiency syndrome that is synergistic with AIDS. Micronutrient
deficiencies are common in HIV but differ among populations.  In the
United States for example, deficiencies are found more commonly in
children than in intravenous drug users who have more than do men who have
sex with men.

Vitamin A deficiency was found in as many as 55% of HIV+ IVDUs in one
study and zinc deficiency in 71% of children. Micronutrient deficiencies
are related to reduced CD4 counts and an increased risk of HIV-related
mortality.  Normalizing vitamin status by supplementation at nutritional
levels has been shown to contribute to improved CD4 counts. (Baum et al.,
1995)Dr. Baum ran through data regarding HIV and a number of the
micronutrients:
Vitamin A: deficiency is associated with increased risk of mother to child
HIV transmission (MTCT); however, supplementation decreased pre-term
births and improved the health of the born children in several studies but
did not decrease MTCT except in pre-term infants in one study; deficiency
has also been associated with decreased CD4 counts and tripling of the
risk of HIV-related death, and is a good predictor of mortality
B Vitamins: deficiencies of vitamin B2, B6, B12 and folate have been
identified; folate and B12 are particularly important to immune function;
B12 deficiency has been associated with an 8-fold increase in mortality
risk; supplementation above the RDA is necessary to see benefits.
Vitamin E: deficiency has been found in 15-50% of HIV-infected people,
depending on the population and study; status depends on dietary intake
and stage of disease with higher levels associated with slower progression
to AIDS and decreased mortality.
Selenium: the most important antioxidant trace element in the body; in one
study only 7% of patients had selenium deficiency, and all subjects died,
but survival time was greater in those with adequate status and the
relative risk of HIV-related mortality was 20 in the deficient
individuals; similar findings in children and men who have sex with men.
Zinc: deficiency symptoms are similar to AIDS including reduced immune
function, decreased appetite, diarrhea and hypogonadism; activates thymic
hormones to stimulate T cell proliferation; deficiency may contribute to
wasting and is associated with 3 times the risk of HIV-related mortality;
intake of less than 9.34 mg daily was associated with low plasma levels.

Importantly, while many micronutrient deficiencies have been associated
with worsened outcomes, supplementation has had mixed results, including
some quite negative.  Dr. Baum recommends consuming no more than the
recommended daily allowance (RDA) of most micronutrients and avoiding
excessive intake, especially of Vitamin A and the trace elements.

Asked about the role of micronutrient supplementation in the context of an
inadequate food supply, Dr. Baum maintained that the individual nutrients
"are not magic", so where food is not currently available, food should be
provided - "like the only solution to drought is rain".

Micronutrients, Pregnancy and Lactation
Dr. Wafaie Fawzi, MD, DrPH of the Harvard School of Public Health in
Boston, Massachusetts, USA also addressed the role of micronutrients in
HIV, but focused more narrowly on pregnancy and lactation. Vitamin A,
perhaps because of the frequent deficiency in developing countries, has
been most widely studied.

Deficiency of Vit A has been linked with increased shedding of HIV virus
into breast milk and increased risk of mother to child transmission. 
However, prenatal supplementation with Vit A in some studies had no effect
on MTCT, while in others it appeared to increase the risk of MTCT.A
longitudinal trial in nearly 900 pregnant women in Tanzania tested4
combinations of Vit A, multivitamins (vitamins B, C and E) and placebo. 
All received standard prenatal care. Surprisingly, multivitamins were
associated with reductions in fetal death, stillbirth, premature birth and
incidence of diarrhea within the first 24 months, as well as increased
birth weight, while Vit A alone had no effect on any of these measures.
And while multivitamins had no effect on MTCT, Vit A actually increased
the risk both prenatally (RR=3D1.38) and during breastfeeding(RR=3D1.33).

No modifiers of the harmful effect of Vitamin A were identified.  However,
the reduction of HIV transmission through breastfeeding with multivitamin
supplements was seen only if other factors were present, such as CD4
counts
<1340 mm3 and hemoglobin <8.5 g/dL in the mother, or birth weight <2500 g, Lymphocyte count, as well as vitamin E levels,
modified the effect of multivitamins on rate of death by 24 months. The
obvious conclusion, and the one made by Dr. Fawzi, is that multivitamins
without Vitamin A should be taken by HIV+ pregnant women.
However, since results have been inconsistent across studies, and since
there appears to be a U-shaped relationship between vitamin A status and
several health measures, it is possible that a role for supplemental
vitamin A in carefully monitored doses will be identified.  Nevertheless,
despite common deficiency but because of the potential risks, the current
recommendation for HIV+ pregnant women needs to be as Dr. Fawzi suggests.

Iron Deficiency and Anemia in HIV Disease
Another common micronutrient deficiency in HIV disease is iron.  This is
one cause of anemia, the topic addressed by Dr. Jean Humphrey of the
ZVITAMBO Project, Zimbabwe and the Johns Hopkins Bloomberg School of
Public Health, Baltimore, MD. Other causes of anemia include additional
nutrient deficiencies (folate and vitamin B12), malignancies, impaired
bone marrow, and chronic disease.  Anemia of chronic disease is common in
HIV.  The mechanism appears to be reduced levels of erythropoietin plus
impairment of the erythroid progenitor response to erythropoietin caused
by elevated cytokines common in HIV.TNF in particular has been
consistently associated with hemoglobin levels; the higher the TNF (and
interleukin IL-1) the lower the Hgb level.  In addition, cytokines impair
iron mobilization from the reticuloendothelial system; despite reduced
serum iron, accumulation of iron in the bone marrow and other tissues has
been identified in many studies.

Although iron deficiency is extremely rare in males in developed countries
it is common in many other groups. The major clinical implication of
anemia is fatigue, which is important for a patient's quality of life. 
Anemia has also been associated with increased rates of mortality in two
large European and American studies conducted primarily in men (Mocroft
1999;Sullivan 1998).The European study found a 57% increase in mortality
with each gram/dL decrease in hemoglobin.

In a recently published study in women in the US (Semba et al, 2002),
anemia was more common in HIV+ intravenous drug users than in those who
were not infected, and again was associated with increased mortality.
Similar results were also found in a ZVITAMBO study (also presented as a
poster at the conference) that followed women in Zimbabwe for 15months
after childbirth.  Those with hemoglobins less than 7 g/dL were 3.5 times
more likely to die during that time period.  Again, there was a stepwise
increase in mortality risk with each g/dL decrement in hemoglobin. Dr.
Humphrey noted that the cause of anemia in this group is more likely to be
iron deficiency than anemia of chronic disease, with iron deficiency
caused by high requirements associated with high parity and excess losses
such as from hookworm, as well as excess destruction such as from sickle
cell.

This is supported by one study from Malawi (Semba 2000), where 70% of HIV+
pregnant women were anemic and 55% were both anemic and had low serum
ferritin, an indicator of iron status. Thus, 79% of the anemia was from
iron deficiency. On the other hand, iron overload contributes to HIV
disease progression.  Dr. Humphrey voiced her opinion that iron
supplementation for HIV+ people who are not deficient is counterproductive
while giving it to those who are is `probably beneficial and probably not
harmful’.

While decision-making should be based on HIV status, ferritin status and
presence of anemia, there is a lot still unknown about the interactions
between them.  In addition, the costs of these tests are usually
prohibitive in resource-poor countries. Thus all three micronutrient
speakers were able to identify the negative impact of deficiencies, found
some benefit to supplementation, but consistently cautioned against
excessive intake of some nutrients, particularly vitamin A, iron and some
other trace minerals.

Toxicities of all of these are well known in people without HIV as well.
Since people fighting a chronic infection such as HIV often have increased
requirements, the best recommendation appears to be some supplementation
of the safer vitamins, while in order to ensure adequate intake of the
others and the macronutrients carbohydrate, fat and protein, a sufficient
and varied diet must be at the foundation.  This is the challenge of
agriculture, nutrition and medical professionals working in resource poor
areas where food insecurity exists for entire populations.

Tuberculosis (TB)
Dr. Derek Macallan of St. George's Hospital, London reviewed the role of
tuberculosis in HIV-related nutrition complications.  TB is another
growing problem in both rich and poor countries. A post-mortem study from
the Cote d'Ivoire in people with a clinical diagnosis of AIDS wasting
found a 42% prevalence of TB, with many having combined HIV, TB and
diarrhea (Lucas SB et al., BMJ 1994; 308:1531).TB has major effects on
nutritional status - previously known as `consumption', it looks very much
like HIV wasting, with weight losses of 15-25% including significant loss
of muscle mass and hypoalbuminemia..

This can contribute to an inability to distinguish between HIV and TB on
clinical presentation. However, the combination of both infections results
in greater declines in body cell mass(BCM) and fat mass than HIV alone
(Paton 1999).In contrast, there is no difference in body cell mass, fat
and fat free mass between TB-infected people with or without HIV (Shah
2001).

Again, the importance of decreased food intake during illness is noted. 
While weight loss during acute TB is significant, one study found no
change in resting energy expenditure after recovery. Although REE prior to
infection was not available, the likely conclusion is that weight loss
during illness is due to decreased caloric intake, and regain of weight
after illness is due to improved intake. TB and HIV do not have precisely
the same effects, however. For example, protein turnover appears to be
increased in HIV and AIDS but not in TB.

Medical/nutritional management of people co-infected with HIV and TB has
not been widely studied but a few interesting pieces were presented. For
example, the anti-TNF drug thalidomide has a greater effect on weight gain
over 28 days in co-infected people than in HIV alone (Klausner G et al.,
1996).  Also, zinc and vitamin A supplementation had a small but
significant effect on speed of recovery from TB in co-infected people
(Karyadi AJCN 2002).

A study in 1961 found that treatment in a sanitorium had better response
than treatment at home, with the only identifiable difference being
greater availability of adequate nutrition (Ramakrishnan CV et al., Bull
WHO 1961; 25: 339).

Dr. Macallan concluded that HIV care cannot be successful without adequate
TB treatment and that adjunctive nutritional and other treatments may
improve both quality of life and response to TB antibiotic therapy. During
the question and answer period, he added that susceptibility to TB, the
pattern of disease and the recovery period may all be worsened if there is
prior malnutrition.

Nutritional Therapy
Dr. Kotler returned to discuss the goals of nutritional therapy, which he
summarized as minimizing losses, repletion after losses, and improvement
of functional status and quality of life.

Therapies fall into 3 categories: treat the underlying disease whether
HIV, TB or other opportunistic infections; promote increased food intake
whether through improved food supplies, appetite stimulants or
non-volitional feeding; and affect metabolism through anabolic agents,
cytokine inhibitors, or exercise. Although antiretroviral agents have
improved nutritional status and decreased wasting, nutritional problems
continue to occur and require intervention.  Prior to the availability of
even AZT, Dr.Kotler found that treating cytomegalovirus (CMV) reversed
weight, body cell mass, and fat losses, and increased serum albumin and
energy levels.

Dietary counseling appears to help half of people across studies. Many
interventions, however, result in primarily fat gain without adequate
repletion of body cell or fat free mass.  This includes liquid nutritional
supplements whether orally or via tube feeding, appetite stimulants such
as Megace and Marinol, and parenteral nutrition. However, the response
differs according to underlying illness; with TPN, BCM increased 14% in
those with malabsorption but decreased 8.5% in those with systemic
infections (Kotler et al, JPEN1990).

In addition to the increased need for protein to fight infections, wasting
in turn suppresses the gonadal axis and hypogonadism is common in men and
women. Drug Therapy Interventions that have had some success in repletion
of body cell mass include testosterone and other anabolic agents,
including oxandrolone, with and without exercise, and growth hormone.
Another treatment approach, the anticytokine thalidomide, also promoted
weight increase, 2/3 of which was FFM (Kaplan 2000).A study from Kotler's
lab (Agin et al, Ann NY Acad Sci 2000) compared combinations of a whey
protein supplement and resistance exercise, thus avoiding much of the
expense of medications.

In 30 women with body cell mass depletion, supplemental protein increased
weight, BCM and fat; exercise increased BCM and strength but decreased
fat; and the combination increased weight, BCM, fat and strength. Need for
Adequate Food Intake As Dr. Kotler showed, food alone is often not
adequate to reverse the malnutrition associated with HIV.  However,
without adequate food, the more expensive and/or intensive interventions
would have no substrate for the metabolic processes involved to prevent
malnutrition and rebuild.

Thus speakers in the nutrition session consistently addressed the need for
adequate food.  This was supported by a World Food Programme of the UN
press release the week prior to the conference in which the WFP's deputy
director of operations was quoted as saying that `having enough food and
the right kind of food has been a long overlooked remedy in the fight
against HIV/AIDS.  Food helps interrupt the downward spiral of
malnutrition, increased fatigue, illness and decreased work productivity. 
As important as drugs and education are to combating the disease, food is
a first defense that keeps people healthier longer...

Food is a fundamental need for people suffering with HIV/AIDS.’ But
adequate food does not exist in much of the world, and HIV worsens this
situation in many ways, as described by several of the speakers in the
Food Security session.  First, the requirements during even early
infection are increased, as discussed above.  Then, as people become ill
and die, they are no longer able to contribute to the production of food.
Many return from urban areas to homes in rural areas to be cared for by
family, and family members are drawn away from farming when they are
needed to tend to the ill and to attend the funerals of their relatives
and neighbors.

Often a `cash crop' is grown while the family subsistence garden is
ignored.  Assets, including the family cow, may be sold to pay for medical
care and funeral costs. Women who become widowed are frequently divested
of their husband's property, including land and farming tools by male
relatives.

Finally, the creation of vast numbers of orphans by this disease means
among other things that a generation is not being taught how to best
produce food.  They are also not attending school where food programs
supplement household food needs. As a result of all of these factors, the
food supply in much of the world is becoming more limited in quantity as
well as quality.  HIV is one contributor to the fact that Africa is the
only continent that has not increased its food production in the past 30
years.

In Malawi, 93% of households have experienced a decrease in agricultural
productivity. The lack of food complicates nutritional management in poor
settings.

Dr. Nigel Rollins of the Department of Paediatrics, University of Natal
and Africa Centre for Health and Population Studies, South Africa spoke of
children with chronic diarrhea, who usually present to his hospital with
multiple diseases, and frequently die.  This year, more than 60% of the
children have been HIV+ and 76% of the deaths have been in those with HIV.
The death rate increases 3-fold if the diarrhea is from cryptosporidiosis.
 Typically the children are rehydrated, treated for sepsis and
nutritionally managed.

In those with HIV the management is complicated by severe carbohydrate
(monosaccharide -lactose, sucrose and glucose) intolerance due to
destruction of the intestinal villi.  Weight gain is very difficult to
achieve, even with lactose- and sucrose-free, semi elemental and
intravenous feedings.

Standard Vs Enhanced Support
Dr. Rollins presented preliminary results from a randomized non-blinded
study of standard vs `enhanced' nutritional support (ENS) for3-6 months
after discharge from the hospital.  The 169 children averaged a year old
and 3 standard deviations less than normal weight and length.  After 8
weeks of low lactose, high protein and high calorie feedings of standard
infant-feeding products in addition to the standard nutrition counseling
and multivitamin supplements, the children in the ENS group gained weight
and reached 2.3=B11.5 SD below average weight for age vs -2.9=B11.5 SD in
the standard group. And whether or not ENS was continued after the first 3
months, that group continued to gain weight to a greater extent than the
standardly supported group (-1.5 vs -2.6 SD).  Despite the significant
weight gains, however, there was no difference between the groups in
number of subsequent diarrhea episodes, CD4 counts or mortality. Numerous
pathogens were identified in the diarrhea, and it may be that issues of
food and water safety need to be addressed to prevent the initial
destruction of the villi. The information about nutrition that has been
learned through the experience and research of these session speakers and
others needs to be imparted to people living with HIV/AIDS and their
professional and non-professional caregivers.  However, the unique
challenges of the developing world must be understood and incorporated
into the nutrition field in those areas.

Nutrition Complications in India
Bhawna Sati, a nutritionist with the FXB Rajasthan Society in India spoke
of the challenges in treatment of nutrition complications in her country. 
At the comprehensive care project where she works, only41% of the patients
can afford to purchase their complete nutritional requirements while 9%
can only afford half of what they need. Even those who can afford food do
not have access to a wide range of food types. Other challenges include
poor hygiene and lack of safe water, addictions, and poor nutrition
knowledge complicated by cultural food taboos.

Dietary counseling at the center focuses on these issues. Some groups
experience additional challenges.  Pregnant and lactating women have
increased nutritional requirements, especially since breastfeeding tends
to be prolonged.  Low birth weight is common and the effects of maternal
malnutrition linger.  Children have strong food likes and dislikes, and
girls experience sex discrimination that limits their food choices. 
Symptomatic patients have many of the same problems described in wealthy
countries, including stigma, opportunistic infections, and decreased
appetite and lean body mass, but additionally cannot afford the necessary
therapies.

Resources for Assistance
Dr. Eleonore Seumo of the Food and Nutrition Technical Assistance Project
of the Academy for Educational Development of USAID described some
resources available to those interested in addressing the nutrition
challenges of developing countries. HIV/AIDS: A Guide for Nutrition, Care
and Support was developed as a generic guide to provide nutrition
information to program managers previously exposed to discrepant nutrition
advice, to help them advise households affected by HIV/AIDS.

The need for guidelines based on sound nutritional science but also
varying cultural norms and needs led to the development of the handbook
Developing National Guidelines on Nutrition and HIV/AIDS, which will be
available shortly. Such guidelines are being developed in Uganda, where a
defined set of steps have been followed.  A situational analysis was
conducted to identify problems associated with nutrition and HIV/AIDS
nationally, then a workshop was held to produce a national plan for the
development of the guidelines based on the problems identified during the
situational analysis. The plan called for `multisectional stakeholder'
meetings to be held locally.

Finally, it was decided to develop a booklet of messages from the national
guidelines that can be expanded and adapted to different contexts within
small localities.  Dr. Seumo advised that recommendations must be
feasible, based on food availability, affordability and cultural
acceptance.  Nutrition interventions should be integrated into existing
HIV programs, including prevention efforts.  They must also fit into the
livelihood strategy of the individual to be accepted at the personal
level.

Similar advice was given by Cade Fields-Gardner, who has been working with
groups in Africa since the last international AIDS conference. She
described `nutritional insecurity' as when someone's nutritional status is
at risk because of poverty, illness, lack of information, stigma, lack of
access to healthcare, and lack of access to food.

The development of nutrition guidelines for people with HIV who are
experiencing nutritional insecurity requires a comprehensive approach to
assessment of risk factors and interventions to minimize risk. She
suggests collaborations between nutrition professionals and existing
programs, including governments and non-governmental organizations from
the national to local levels to develop guidelines that are
population-specific, taking culture, gender and age of the patient or
population into account.

A wide range of guidelines and interventions are needed and possible,
addressing basic symptom management, individual psychosocial and economic
interventions, nutrition and food programs at the clinical level attached
to medical intervention programs, and community programs.

As one speaker said, the battle has begun and the battle must be won.

07/31/02
References
Agin D, Kotler DP, Papandreou D, Liss M, Wang J, Thornton J,Gallagher D,
Pierson RN Jr. Effects of whey protein and resistance exercise on body
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