Clinical Nutrition: Hiv/aids

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HIV requires which enzyme once inside the DNA

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Reverse Transcriptase

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HIV/AIDS invades genetic code of CD4 cells which are

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receptor sites of T helper lymphocytes

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HIV Test:

ELISA

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tests for the HIV antibodies

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HIV Test:

Western Blot

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confirms ELISA

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HIV Test:

Viral Load

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Amount of virus found in blood

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HIV Test:

Oral and Urine

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Require confirmation test

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HIV Test:

Rapid Test

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Fingerstick, quick results, approved 2002

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All tests requires counseling including

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1. Risk assessment

2. Risk reduction

3. Emphasize importance of decreaseing transmission

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CDC Defines HIV as

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+ HIV test

CD4 count > 200

lack of opportunistic infection

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CDC Defines AIDS as

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+ HIV test

CD4 count < 200

presence of opportunistic infections

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CD4/T lymphocytes Stage 1

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> 500 cell/ul

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CD4/T lymphocytes Stage 2

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200-499 cell/ul

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CD4/T lymphocytes Stage 3

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< 200 cell/ul

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Clinical Categories

Stage 1

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asymptomatic HIV infection, generalized

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Clinical Categories

Stage 2

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symptomatic but no AIDS-defining condition

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Clinical Categories

Stage 3

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Presence of AIDS-defining condition

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Lab Tests related to Dx

Viral Load

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# of viral particles measured in the blood

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Lab Tests related to Dx

CD4 count

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Amount of T helper lymphocytes remaining

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Malignancies

Kaposi Sarcoma

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affects mouth, oral cavity, intestinal tract

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Malignancies

Lymphoma

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leads to malabsorption, diarrhea, intestinal obstruction

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HIV Related Complication

Neurological

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HIV encephalopathy or AIDs dementia

Precipitated by Vitamin deficiency

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HV Related Complication

Liver

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Infections

Co infected with Hep C

Hepatotoxic Meds

AIDS cholangiopathy

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HIV Related Complication

Pulmonary

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TB

PCP (Pneumocystis Pneumonia)

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HIV Related Complication

Kidney

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HIV nephropathy

Proteinuria

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Effects on GI tract

Candidiasis

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Sore Mouth

Dysgeusia (distortion of the sense of taste)

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Effects on GI tract

KS or Herpes

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Sore Mouth

Inhibits Swallowing

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Thrush

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yeast infection in the mouth caused by candida albicans fungus

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Effects on GI tract

Gastric

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Hypochlorhydria (low stomach acid)

CMV, Cryptosporidium, and other parasites

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Effects on GI tract

Small Bowel

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Small Bowel Morphology

Villi shortened and flattened, absorptive areas substantially reduced

lowered Ig A production: affects gut immunology

reduced enzyme leves

CMV, MAC, microsporidia prevalent

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Effects on GI tract

Large Bowel

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CMV colitis

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Effects on GI tract

HIV Enteropathy

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Diarrhea of the second degree

small and large bowel inflammation and malabsorption

Intestinal Mucosal Change

Increase Gut Permeability

Glutamine Supplements

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Lipodystrophy Syndrome

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Fat redistribution, abnormal lipid elves, and insulin resistance

Accumulate abdominal fat and lose fat from face, arms, and legs

Fat deposits accumulate between shoulders

Buffalo Hump and Lipomas

Hypercholesterolemia

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Treatments for Lipodystrophy Syndrome

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Dietary Adjustments

Meds for elevated TG and LDL cholesterol levels and insulin resistance

Aerobic activity

Resistance Training

Cosmetic Surgery

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AIDS wasting

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Involuntary weight loss of 10% body weight, plus more than 30 days of either diarrhea, or weakness and fever

associated with higher morbidity and mortality

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Etiology of AIDS wasting

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Anorexia and reduced food intake

emotional stress and pain

oral & respiratory infections

fatigue, lethargy, and dementia

Meds (taste alterations & food aversions, n/v, diarrhea & malabsorption

Cachexia= changes in macronutrient metabolism and pro inflammatory cytokines

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PEM (protein energy metabolism)

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effects immune function which effects risk of infection

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Treatment for AIDS Wasting

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Aggressive Nutrition Intervention

Appetite Stimulants: magace & marinol

Anabolic Agents: Oxandrin

Oral Nutritional Supplements

Nutritional Support: EN or PN

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Diarrhea/Malabsorption

Small Bowel

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Fat

Mono/disaccharides

B12

Folate

Minerals

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Diarrhea/Malabsorption

Large Bowel

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Fluids

Electrolytes

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Tx for Diarrhea/Malabsorption

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Recommend multi vit/min with B complex

High dose tx should be avoided

MCT oil

Probiotics

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Tx Goals

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decrease viral load

restore/ preserve immune function

improve quality of life

decrease HIV morbidity/mortality

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Drug Treatment

Highly Active Anti Retrovirus Therapy

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Nucleoside/Nucleotide Reverse Transcriptase Inhibitors

Non Nucleoside Reverse Transcriptase Inhibitors

Protease Inhibitors

Entry Inhibitors

Integrase Inhibitors

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Reverse Transcriptase Inhibitors

Nucleoside RTI

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ziagen

viread

epivir (3TC0

Zerit

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Reverse Transcriptase Inhibitors

Non nucleoside RTI

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Viramune

Rescriptor

Sustiva

Intelence (Enravirine) approved as a combo drug 2008 by the FDA

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Reverse Transcriptase Inhibitors act by

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preventing HIV from becoming part of the cell therefore it does not replicate

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Protease Inhibitors

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Invirase

Agenerase

Norvir

Kaletra

Crixivan

Viracept

Prezista

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Protease Inhibitors act by

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preventing the protease enzyme fro cutting the long protein chain. New copies of HIV cannot be made.

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Entry Inhibitors

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Fuzeon T-20

Virus still exists in the system but meds prevent HIV from entering CD4 cells by stopping ti from zipping together the two ends of the glycoprotein and fusing with the host cell

Given as injection

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CCR5 Entry Inhibitors

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Selzentry

blocks CCR5, a protein on the CD4 cells that HIV need to enter the cells

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Intergrase Inhibitors

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Isentress

Works by binding to one of several specific enzymes that HIV uses when copying itself. Once bound to the drug, the enzyme is unavailable to HIV, hindering HIV's ability to make copies of itself

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Immune Based Therapy

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Helps bolster the body's own immune system to help fight the HIV infection

Reproduces cytokines

New therapy and there is no clinical data, regarding its efficacy

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Combo Meds

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Sustive + Epivir + Retrovir or Viread or Zerit

Kaletra + Epivir + Retrovir or Zerit

Combo meds are always recommended b/c the decrease of viral load is only temporary with less than 3 meds

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First Prophylaxis Tx

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FDA approved July 2012

Truvada for use in highly susceptible individuals

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Nutritional Concerns of HIV/AIDS

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wasting, cachexia

GI sx and side effects of meds

Lipodystrophy

Hyperlipidemia

Hyperglycemia

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Nutritional Assessment of HIV/AIDS

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Assess weight hx

% usual, % lost, Anthropometrics

MAC, TSF, CHI

Diet hx

Nutrient Intake, Intolerances

Not traditional therapies

Nutrition Related complications of Sx &Tx

Biochemical Assessment: Alb, Pre alb, Chol, SMA 7, and TLC

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Nutritional Assessment Macronutrients

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Fat

consider MCT if malabportion is present

omega 3 FA are being studied for immune modifying effect

low chol, sat and trans fat secondary lipodystophy

Diet Comp: 45-65 % CHO, 10-35% PRO, and 20-30% Fat

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Low Immune Function to deficiency of

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Vit A

Vit E

Thiamine

Riboflavin

B6 & B12

Folate

Zn

Fe

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Vitamins associated with higher survival

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B vitamins and Vit C

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B12

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low levels are prevalent in HIV pts

etiology may be malabsorption and low intake

dietary supplements may not be enough especially with PI use

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Vitamin A

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low levels associated with MTCT but supplementation has been found to crease risk of MTCT by 38%

U shaped relation between intake and risk of progression to AIDS/death

with in range of 9000 and 20000 expected lower risk

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Vitamin A in children

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reduce diarrheal morbidity by 50% and significantly reduce overall morbidity and mortality

improve growth

lesson the increase in viral load associated with influenza vaccination

increase circulation CD4 and natural killer cells

No significant lower viral load in adults/kids

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Beta Carotene

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results are contradictory

one study showed a positive effect on CD4 counts but another study found no effect on CD4 or viral load

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Vit B, C, and E

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Large doses of a combo of vit c and e were found to reduce oxidative stress and produce a trend towards a reduction in viral load

Three studies showed the RDS for bit b, c, and e helping pregnancy and increase in CD4+ and CD8+ cell counts

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ZInc

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In adults with TB co-infected with HIV, zinc in combo with other micronutrients increased weight gain and survival during treatment

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Special Issues

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CAM

Food Handling

Nutrition counseling and supplementation are beneficial

Research on blu, arg, omega 3, HMB

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Nutriton Intervention

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meet kcal and pro needs

increase LBM

irritated throat/difficulty swallowing

dry mouth/ sore mouth

altered taste

diarrhea

poor appetite