The dangers of overlooking PLHIV nutritional needs 
IN OUR last issue, we looked at the importance of Food and Nutrition for Persons Living with HIV/AIDS (PLHIV), and examined the implications of insufficient or inadequate dietary intake for persons on antiretroviral therapy (ART).
This week, we continue to focus our attention on the dilemma of PLHIV who lack the wherewithal to ensure adequate nutritional intake, thereby seriously challenging the continued efficacy of the therapy which means life to them in the absence of a cure for HIV.
Over the last few weeks, food prices have skyrocketed dramatically locally, and the average household is now finding it difficult to afford a balanced diet on a daily basis, much more low-income or unemployed PLHIV, particularly those on ART.
The reality is that despite the emphasis being placed on other areas of HIV intervention, not enough is being done to ensure the bulk of the people being placed on therapy can feed themselves, as the guidelines for intake of the anti-HIV medication demand.
Unless this proverbial ‘bull’ is taken by the horn, without delay, access to ART locally can pretty much be expected to take on another dimension, one for which our economy is not prepared.
Whereas many developing countries are handling the situation with kid gloves and have difficulty with admitting that, for many PLHIV, the benefits of ART could be short-lived, and give way to drug resistance and ultimately death, because the users cannot afford to eat as the treatment demands. This is according to international experts, who continue to sound a warning bell. 
In the event you missed our last issue, here is what a team of experts from the United Nations (UN) and FAO (Food and Agriculture Organisation) had to say as they addressed journalists at an International AIDS Conference on the issue of Nutrition and HIV:
Said Professor Alan Whiteside of the Health, Economics and HIV/AIDS Research Division (HEARD):   “As food prices continue to rise, people in developing countries are struggling to afford a balanced diet, which is crucial to the success of antiretroviral (ARV) treatment.  Millions living with HIV lack adequate food and basic nutrition necessary to maximize the drugs’ effectiveness, or to support young children orphaned or affected by HIV and AIDS.”      
He further warned: “… advances in the treatment of HIV risk being undermined, unless the international community acts to mitigate the effects of the global food crisis and provide basic nutritional support to those in need.”
And, as Dr. Martin Bloem, Chief HIV/AIDS and Nutrition Service, UN World Food Population, declared:  “People underestimate the impact high food prices have on nutrition.  Nutrition support is especially important, as the present food crisis poses a fundamental threat to millions of vulnerable people.”
Noting that micronutrient deficiencies and protein energy malnutrition, both of which have detrimental effects on the immune system, are now on the increase, Dr. Bloem cautioned:  “This obviously means higher mortality, especially for those living with HIV.”
And UNAIDS Special Adviser, Robin Jackson, equally concerned about this development, warned:  “Putting people on treatment without ensuring they have enough to eat, is like sending your kids to school without any books.” 
Jackson observed that with high food prices being here to stay in the foreseeable future, it is critical to supplement HIV and TB programmes with a nutritional component.
“If we fail now, there will be more dramatic consequences for people living with HIV,” she reiterated. She, too, explored the impact of high food prices and lack of resources to handle  the increased appetite that comes with starting drugs (ARV), mentioning that many PLHIV often cannot even afford the cost of travelling to clinic.
“As a result, people are not starting treatment, and others on treatment are discontinuing their drug regimen,” she remarked. 
However, with the success of the rolling out of ‘universal access’,  numbers now on ART have increased dramatically, with more than five million now being reached.
Picking up on this issue, USAID HIV/AIDS website, in its article, A Wholesome Approach: Nutrition and HIV/AIDS, critically examines the issue.
“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 programme guidance on nutritional care and support interventions, the nutrient requirements of PLWHA, and food and nutrition complications of antiretroviral therapy.”

Nutritional/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.

Good nutrition and 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 (OVC) 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.
Since the inception of its HIV/AIDS programme in 1986, the U.S. Agency for International Development (USAID) has been on the forefront of the global AIDS crisis, investing more than $7 billion to fight the pandemic.
Today, with more than 33 million people living with or affected by HIV/AIDS, USAID is a key partner in the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the largest and most diverse HIV/AIDS prevention, care, and treatment initiative in the world.