Macronutrient Supplementation for Malnourished HIV-Infected Adults: A Review of the Evidence in Resource-Adequate and Resource-Constrained Settings

Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
Clinical Infectious Diseases (Impact Factor: 8.89). 10/2009; 49(5):787-98. DOI: 10.1086/605285
Source: PubMed


Access to antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection has expanded rapidly throughout sub-Saharan Africa, but malnutrition and food insecurity have emerged as major barriers to the success of ART programs. Protein-calorie malnutrition (a common form of malnutrition in the region) hastens HIV disease progression, and food insecurity is a barrier to medication adherence. Analyses of patient outcomes have identified a low body mass index after the start of ART as an independent predictor of early mortality, but the causes of a low body mass index are multifactorial (eg, normal anthropometric variation, chronic inadequate food intake, and/or wasting associated with HIV infection and other infectious diseases). Although there is much information on population-level humanitarian food assistance, few data exist to measure the effectiveness of macronutrient supplementation or to identify individuals most likely to benefit. In this report, we review the current evidence supporting macronutrient supplementation for HIV-infected adults, we report on clinical trials in resource-adequate and resource-constrained settings, and we highlight priority areas for future research.

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Available from: Douglas C Heimburger,
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    • "Over the last 10 years, the World Health Organization (WHO) and other international organizations have issued recommendations that nutritional assessment, counseling, and support be a standard part of comprehensive care for HIV (FANTA, 2004; World Bank, 2007; World Health Organization, 2008). While research generally finds a positive effect of supplemental feeding on the nutritional status and HIV outcomes of underweight PLHIV (Koethe, Chi, Megazzini, Heimburger, & Stringer, 2009; Tirivayi & Groot, 2011), providing food support to overweight or obese PLHIV may result in further weight gain even if food security improves (Larson & Story, 2011; Leroy, Gadsden, de Cossío, & Gertler, 2013), putting PLHIV at risk for chronic comorbidities such as diabetes and cardiovascular disease. With data from a pilot intervention study in Honduras, we investigated how food support combined with nutrition education influences food security and body weight, compared to nutrition education alone, in a population with high food insecurity and diverse nutritional statuses. "
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    ABSTRACT: Optimal strategies to improve food security and nutrition for people living with HIV (PLHIV) may differ in settings where overweight and obesity are prevalent and cardiovascular disease risk is a concern. However, no studies among PLHIV have investigated the impact of food support on nutritional outcomes in these settings. We therefore assessed the effect of food support on food insecurity and body weight in a population of PLHIV with high prevalence of overweight and obesity. We implemented a pilot intervention trial in four government-run HIV clinics in Honduras. The trial tested the effect of a monthly household food ration plus nutrition education (n = 203), compared to nutrition education alone (n = 197), over 12 months. Participants were clinic patients receiving antiretroviral therapy (ART). Assessments were obtained at baseline, 6 and 12 months. Primary outcomes for this analysis were food security, using the validated Latin American and Caribbean Food Security Scale and body weight (kg). Thirty-one percent of participants were overweight (22%) or obese (8%) at baseline. At 6 months, the probability of severe food insecurity decreased by 48.3% (p < 0.01) in the food support group, compared to 11.6% in the education-only group (p < 0.01). Among overweight or obese participants, food support led to average weight gain of 1.13 kg (p < 0.01), while nutrition education alone was associated with average weight loss of 0.72 kg (p < 0.10). Nutrition education alone was associated with weight gain among underweight and normal weight participants. Household food support may improve food security but not necessarily nutritional status of ART recipients above and beyond nutrition education. Improving nutritional tailoring of food support and testing the impact of nutrition education should be prioritized for PLHIV in Latin America and similar settings.
    AIDS Care 11/2014; 27(4):1-7. DOI:10.1080/09540121.2014.983041 · 1.60 Impact Factor
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    • "Nutritional interventions have been successful in the management of HIV and AIDS, and many patients enrolled into such programs have markedly improved both their body weight and general health [7]. The Food by Prescription program is one of the strategies that addresses undernutrition among PLHIV and their vulnerable family members through nutritional assessment, counseling, and support (NACS) [8,9]. "
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    ABSTRACT: Background One way of addressing malnutrition among HIV/AIDS patients is through the Food by Prescription program (FBP) and many studies have explained the treatment outcomes after therapeutic food supplementation, though available evidences on adherence levels and factors associated with these sorts of programs are limited. The findings of this study would therefore contribute to the existing knowledge on adherence to Ready-to-Use Therapeutic/Supplementary Food (RUF) in Ethiopia. Methods A facility-based, cross-sectional study supplemented with qualitative methods was conducted among 630 adult HIV + patients. Their level of adherence to RUF was measured using the Morisky 8-item Medication Adherence Scale (MMAS-8). The total score on the MMAS-8 ranges from 0 to 8, with scores of <6, 6 to <8, and 8 reflecting low, medium, and high adherence, respectively. Patients who had a low or a moderate rate of adherence were considered non-adherent. Results The level of adherence was found to be 36.3% with a 95.0% response rate. With the exception of the educational status, other socio-demographic variables had no significant effect on adherence. Those who knew the benefits of the FBP program were 1.78 times more likely to adhere to the therapy than the referent groups. On the other hand, patients who were not informed on the duration of the treatment, those prescribed with more than 2 sachets/day and had been taking RUF for more than 4 month were less likely to adhere. The main reasons for non-adherence were not liking the way the food tasted and missing follow-up appointments. Stigma and sharing and selling food were the other reasons, as deduced from the focus group discussion (FGD) findings. Conclusion The observed level of adherence to the FBP program among respondents enrolled in the intervention program was low. The major factors identified with a low adherence were a low level of education, poor knowledge on the benefits of RUF, the longer duration of the program, consuming more than two prescribed sachets of RUF per day, and not being informed about the duration of the treatment. Therefore, counseling patients on the program’s benefits, including the treatment plans, would likely contribute to improved adherence.
    Infectious Diseases of Poverty 06/2014; 3(1):20. DOI:10.1186/2049-9957-3-20 · 4.11 Impact Factor
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    • "A large percentage of the cohort had low body weight at baseline and consistent with other ART Programmes [33], [34], [49] the probability of retention was lower in patients with low body weight at ART initiation. Although it is not known whether undernourishment is causally related to poor ART outcomes or is merely associated [61], hunger is a frequently reported barrier to adherence and the side effects and toxicity of some ARVs can be potentiated if taken without food [62]. Adoption of food supplementation as a strategy aimed at increasing patient retention would be useful in our setting. "
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    ABSTRACT: Since establishment of Zimbabwe's National Antiretroviral Therapy (ART) Programme in 2004, ART provision has expanded from <5,000 to 369,431 adults by 2011. However, patient outcomes are unexplored. To determine improvement in health status, retention and factors associated with attrition among HIV-infected patients on ART. A retrospective review of abstracted patient records of adults ≥15 years who initiated ART from 2007 to 2009 was done. Frequencies and medians were calculated for rates of retention in care and changes in key health status outcomes at 6, 12, 24 and 36 months respectively. Cox proportional hazards models were used to determine factors associated with attrition. Of the 3,919 patients, 64% were female, 86% were either WHO clinical stage III or IV. Rates of patient retention at 6, 12, 24 and 36 months were 90.7%, 78.1%, 68.8% and 64.4%, respectively. After ART initiation, median weight gains at 6, 12, and 24 months were 3, 4.5, and 5.0 kgs whilst median CD4+ cell count gains at 6, 12 and 24 months were 122, 157 and 279 cells/µL respectively. Factors associated with an increased risk of attrition included male gender (AHR 1.2; 95% CI, 1.1-1.4), baseline WHO stage IV (AHR 1.7; 95% CI, 1.1-2.6), lower baseline body weight (AHR 2.0; 95% CI, 1.4-2. 8) and accessing care from higher level healthcare facilities (AHR 3.5; 95% 1.1-11.2). Our findings with regard to retention as well as clinical and immunological improvements following uptake of ART, are similar to what has been found in other settings. Factors influencing attrition also mirror those found in other parts of sub-Saharan Africa. These findings suggest the need to strengthen earlier diagnosis and treatment to further improve treatment outcomes. Whilst decentralisation improves ART coverage it should be coupled with strategies aimed at improving patient retention.
    PLoS ONE 01/2014; 9(1):e86305. DOI:10.1371/journal.pone.0086305 · 3.23 Impact Factor
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