Transcript File - Kamilan Aurielle Lowery

HIV/AIDS and Nutrition
Source: http://hiv.health.gov.tt/
Ali Aziz, Aurielle Lowery, Sarah Vacher,
Tessa Englund, and Xiaolu Hou
Objectives
■ Examine HIV’s history, etiology, & effects on the human body
■ Explain the impact of HIV on nutritional status & vice versa
■ Discuss nutrition assessment methods for an HIV patient
■ Identify nutrition diagnoses for the case patient & other
common diagnoses for HIV/AIDS patients
■ Identify nutrition interventions for HIV/AIDS patients
■ Discuss common goals/outcomes as well as time frames
for nutrition monitoring & evaluation
■ Use a male case patient with AIDS-Stage 3 with oral thrush
to facilitate more detailed exploration of the topics above
Case Patient T.L.
■ 32-year-old African American
male, 6’1”, 151# CBW, and 160165# UBW
■ HIV diagnosed 4 years ago but
had never been treated for it PTA
■ Admitted with very sore mouth/
throat, likely PNA & progression
to AIDS, mild malnutrition, & 8.5%
weight loss compared to UBW.
■ Diagnosis of AIDS-Stage 3 with
thrush & no clinical evidence of
PNA. HAART initiated with Atripla.
Sources: http://remediesforthrush.blogspot.com/2013/09/oral-thrush-infection-and-solution.html
http://recommendpills.com/candidiasis-symptoms-and-treatment/04/11/2012/
HIV/AIDS and Nutritional Status
Epidemiology and Trends
◻ The first cases of AIDS
were described in 1981.
Soon after, HIV was
identified as leading to
AIDS.
◻ At the end of 2008 an
estimated 33.4 million
people lived with either
AIDS or HIV.
Acquired immune deficiency
syndrome (AIDS) is caused
by Human Immunodeficiency
virus (HIV) .
HIV affects the body’s ability to
fight off infection and disease.
Nutritional status plays an
important role in maintaining a
healthy immune system.
HIV Transmission
• HIV is transmitted via direct contact with infected fluids
– Blood, semen, pre-seminal fluid, vaginal fluid, breast milk
– Cerebrospinal fluid, synovial fluid, amniotic fluid
• Sexual transmission is most common
• Saliva, tears, and urine do NOT contain enough HIV for
transmission
Source: http://www.prideglv.org/how-do-you-get-hiv/
HIV-1 vs HIV-2
• HIV-1 infection is what we are
referring to unless specified
otherwise
• HIV-2 is endemic in West
Africa
– Lower viral loads, longer
asymptomatic period,
lower mortality rates than
HIV-1
– Rarely seen outside of
Africa or areas with
strong ties to affected
areas in Africa
Sources: http://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/24/hiv-2infection
Stages of HIV Infection
• HIV progresses through four clinical stages
–
–
–
–
Acute HIV infection
Clinical Latency
Symptomatic HIV infection*
Progression of HIV to AIDS*
• Two main biomarkers to assess disease
progression
– HIV RNA (viral load)
– CD4 (T-helper cell) count
1: Acute HIV Infection
• Time from transmission of HIV to the host
until production of detectable antibodies
– This is called seroconversion
• Non-specific clinical features and very
short diagnostic window
– Acute HIV infection is rarely discovered
2: Clinical Latency
• Also called asymptomatic HIV infection
• Further evidence of illness might not show for as
long as 10 years post-infection
• Virus is active and replicating at a slow rate
• Long-term non-progression
– Here CD4 count levels remain WNL and viral loads can be
undetectable for years
– Not everyone experiences clinical latency for so long
3: Symptomatic HIV infection
• Over time HIV breaks down the immune
system and the body is incapable of fighting
off the virus
• Here CD4 counts fall below 500 cells/mm3
• Pt likely to develop s/s
– Persistent fevers, chronic diarrhea, unexplained
weight loss, recurrent fungal or bacterial
infections
4: Progression of HIV to AIDS
• Immunodeficiency continues to worsen and
CD4 counts fall lower
• Increased risk of opportunistic infections
(OIs)
• CDC defines AIDS as:
– Lab confirmation of HIV infection in person with a CD4+
count below 200 cells/mm3 (or less than 14%)
– Documentation of an AIDS-defining condition
• Krause, pg 866, Box 38-1
Case Study Patient
Pt believes HIV has progressed to AIDS because
he is experiencing:
● exhaustion
● sore mouth and throat (thrush)
● unintended weight loss
● possible pneumonia diagnosis
Source: http://www.cell.com/cms/attachment/531402/3640755/gr2.jpg
Opportunistic Infections
● Candidiasis of bronchi, trachea, esophagus, or lungs infection caused by yeast (commonly known as thrush)
● Cryptococcosis - parasitic infection in small intestine
● Cryptosporidiosis - chronic intestinal infection
(greater than 1 month's duration)
● Tuberculosis - bacterial lung infection
● Pneumonia, recurrent
⬜ PCP - form of PNA caused by fungus
These typically present themselves during
Source: Mahan LK, Escott-Stump S, Raymond JL. Krause's Food & the Nutrition Care Process. 13th ed. St. Louis, MO: Saunders; 2012.
Other Common Complications
AIDS-Defining Conditions
HALS - HIV-associated lipodystrophy syndrome
Wasting - unintentional weight loss
Obesity
Kaposi’s sarcoma - cancerous
connective tissue tumor (pictured)
Lymphoma - blood cell tumors
HIV encephalopathy - neurodegenerative
disorders (also called HIV-associated
dementia)
Chronic liver disease
Source: http://www.dermis.net/dermisroot/en/1270069/image.htm
Impact on Nutritional Status
■ Vitamin and mineral deficiencies are common
■ Resultant of:
⬜ malabsorption
⬜ drug-nutrient interactions
⬜ altered metabolism
⬜ altered gut & gut barrier function
■ Commonly low: Vitamin A, zinc, and selenium
Impact on Nutritional Status
■ Low levels of vitamin A, vitamin B12, and zinc
are associated with faster disease progression
■ Higher intakes of vitamins B and C have been
associated with increased CD4 counts and slower
disease progression
■ No evidence that megadosing is helpful
Case Study Patient - Vitamins
Pt diet should be assessed to ensure that he is receiving
DRI’s, especially for:
➢
➢
➢
➢
➢
➢
➢
Vitamin B12
Vitamin A
Vitamin E
Vitamin D
Selenium
Zinc
Iron
Because pt is a “picky eater” and has mouth sores that
make eating uncomfortable, RD needs to work with him to
get adequate nutrients while being sensitive to
preferences/pain.
CD4 Count
■ Indicator of immune function &
stage of HIV infection
■ Used to determine whether to
initiate antiretroviral therapy
(ART), which suppresses viral
loads to increase quality of life
and reduce M&M
Case patient has low T-helper cell counts (CD4) indicating
immune suppression and progression to AIDS.
Source:
Treatment Types: HAART
HAART = Highly Active Antiretroviral Therapy
(also commonly referred to as ART)
Goals:
● Reach and maintain viral suppression
● Reduce HIV related M & M
● Increase quality of life
● Gain and maintain immune function
Classes of Antiretroviral Drugs
■ Nucleoside and nucleotide reverse
transcriptase inhibitors (NRTIs)
■ Nonnucleoside reverse transcriptase
inhibitors (NNRTIs)
■ Protease inhibitors (PIs)
■ Fusion inhibitors
■ CCR5 (chemokine receptor 5) antagonists
■ Integrase strand transfer inhibitors (INSTIs)
Most common treatment is the
combination of NRTIs + NNRTI or PI
Predictors of Adherence
■ Patients must have the ability and commitment to a
lifelong treatment
■ Understanding of the pros and cons of therapy and
importance of adherence
■ Barriers include:
⬜
⬜
⬜
⬜
⬜
homelessness
low literacy level
depression
dementia/psychosis
illicit drug use
ART Side Effects
ART medications commonly cause the following side effects:
■
■
■
■
■
■
■
diarrhea
fatigue
gastroesophageal reflux
nausea
vomiting
dyslipidemia
insulin resistance
Many ART drugs must be taken on a strict schedule, with or
without food. Consider this when evaluating patient lifestyle,
willingness to take medication, and access to health care.
Source: http://www.pwnfitness.com/harmful-dangerous-side-effects-zinc/
Drug-Nutrient Interactions
Be aware of patient’s medications, vitamins & supplements, and
recreational substances consumed/used in order to prevent
interactions with ART.
Ex: Grapefruit juice and protease inhibitors
(PIs) both compete for cytochrome P450
enzyme. Grapefruit consumption can lead
to either increased or decreased blood levels
of the drug.
Tables 38-2 through 38-5 in the Krause textbook
break down specific drugs, interactions, and side effects.
Source:
Cost of Therapy
■ According to the CDC treatment usually
costs $2000 - $5000 a month
■ About half of those diagnosed with HIV
do not have regular health care
■ 42% are on Medicaid & 24% are uninsured
■ For the uninsured many will qualify for the
AIDS Drug Assistance Program
⬜ Many states have an income cutoff of about $22,000/year
■ Estimated survival time of 24.2 years after HIV diagnosis yields the
following costs:
⬜ Lifetime on discounted treatment: $385,200
⬜ Lifetime without discount: $618,900
Source: http://blogs.scientificamerican.com/observations/2011/01/12/cost-of-cancer-care-projected-to-jump-nearly-40-percent-by-2020
Cost Breakdown
Just FYI...HIV/AIDS costs the US about $12 billion
annually in health care-related expenses!
■ ART Drugs 73%
■ Inpatient Costs 13%
■ Outpatient Costs 9%
■ Other HIV-related
Medication & Lab Costs 5%
Nutritional Implications
RDs need to take into consideration:
■
■
■
■
■
■
■
Medications
Disease Complications & Combinations
Immunity
Quality of Life
Altered Metabolism
Dietary Habits
Health Care Access
Energy Expenditure
■ Research suggests that patients may have up to a 10%
increase in resting energy expenditure in
asymptomatic HIV patients. That number can rise to
up to 20 - 50% after an opportunistic infection (OI).
▪ Opportunistic Infections: These infections
take advantage of a weakened immune system.
Those with immuno-deficiencies can face
serious threats from viruses and other microbes
that healthy individuals would not even
experience symptoms from.
Source: http://www.healthline.com/health-slideshow/hiv-opportunistic-
Nutrient Breakdown
■ PROTEIN: DRI of 0.8 g/kg IBW is recommended for
healthy or asymptomatic individuals, however it should
increase if REE is calculated at an increased rate.
⬜ Also increase by 10% after an OI
■ FAT/CHO: Keep intake relative to total calories. There is
evidence to support increasing Omega-3 fatty acids in the
diet and keeping saturated fats low.
■ MICRONUTRIENTS: There is NO evidence to support
doses of micronutrients above the DRI.
■ It is important to monitor individual nutrients and to
do so on a patient-by-patient basis
Special Considerations:
Wasting, Obesity, & HALS
Wasting: unintentional weight loss and loss of LBM which are
associated with disease acceleration and mortality.
■ Caused by a combination of possible factors such as poor dietary
intake, nutrient malabsorption, increased metabolic rate, or
various other metabolic complications.
■ Case Pt: Recent undesired weight loss of 6-9% UBW (9-14 lb.)
Obesity: some ART medications increase risk of hyperlipidemia,
insulin resistance, and diabetes. Monitor these values and
encourage both aerobic and resistance training activities.
HALS: HIV-Associated Lipodystrophy Syndrome
■ HALS refers to the abnormalities in fat distribution similar to
metabolic syndrome. Fat accumulation in the abdominal or
dorsocervical region are common. Fat atrophy in the extremities,
face, and buttocks are also common.
Nutritional Implications of HALS
Common problems associated with HALS include:
■ Insulin Resistance
■ Hyperglycaemia
■ Dyslipidemia
■ high total cholesterol and triglycerides, lowered HDL
cholesterol, elevated LDL cholesterol
■ Type II diabetes mellitus
Nutritional interventions should be targeted towards patients
individual symptoms and problems. There are no current major
nutritional treatments for the lipodystrophy itself, but increasing
fiber intake and physical activity may offer slight benefit.
Examples of HALS
Source: http://www.nature.com/nrendo/journal/v8/n1/images/nrendo.2011.151-f2.jpg
http://1.bp.blogspot.com/-ewQ6BFHZA6o/T-UahEZ-KFI/AAAAAAAAfwA/-4HonrykycM/s640/collage1.jpg
Case Patient Information for
Nutrition Diagnoses
■ 32-year-old African American
male, 6’1”, 151# CBW, and 160165# UBW
■ HIV diagnosed 4 years ago but
had never been treated PTA
■ Admitted with very sore mouth/
throat, difficulty eating, likely
PNA & progression to AIDS, mild
malnutrition, & recent 6-9% (914 lb.) weight loss from UBW.
■ Diagnosis of AIDS-Stage 3 w/
oral thrush & no evidence of PNA.
HAART initiated.
Sources: http://remediesforthrush.blogspot.com/2013/09/oral-thrush-infection-and-solution.html
http://recommendpills.com/candidiasis-symptoms-and-treatment/04/11/2012/
Case Patient Information for
Nutrition Diagnoses
■ 32-year-old AA male
151# (69 kg) CBW,
160-165# (73-75 kg) UBW,
6’1” (185 cm)
■ Family hx of CAD & HTN
■ EEN:
2360-2740 kcal/d
(MSJx1.4-1.5,
rebuild LBM/infection)
100-125 g protein/d
(1.2-1.5 g/kg IBW)
2,398 mL fluid
(35 ml/kg/d)
■ 24-hr recall shows intake of
~2,000 kcal & 71 g protein
■ HAART regimen Atripla w/
side efx including N/V/D;
anorexia; dysgeusia;
increased cholesterol & TG;
& known interaction w/
alcohol, SJW, garlic, & milk
thistle
■ PTA took MVI, vit C & E,
ginseng, milk thistle, &
echinacea supplements
■ 2-3 beers 3-4 times/week
Nutrition Diagnoses for Case Patient
■ Sample PES Statements for Patient T.L.
⬜ Unintended weight loss (NC-3.2) r/t inadequate oral intake
and mouth pain AEB caloric intake ~73-85% of EEN according
to 24-hr recall; mild malnutrition (82% IBW); and recent
undesired significant weight loss of 6-9% (9-14 lb.).
⬜ Predicted food-medication interaction (NC 2.4) r/t concurrent
use of Atripla, alcohol, milk thistle, and St. John’s wort AEB pt
report of regular alcohol consumption and herbal
supplementation along with recent initiation of HAART using
Atripla (which has known DNIs with alcohol, milk thistle, SJW).
⬜ Food and nutrition-related knowledge deficit (NB-1.1) r/t
lack of prior nutrition-related education AEB self-reported usual
dietary intake (before mouth sores) high in processed foods and
low in fresh nutrient-dense foods; high alcohol consumption;
and excessive vitamin C and E supplementation.
Common Nutrition Diagnoses for
HIV/AIDS Patients
■ Inadequate oral intake (NI-2.1)
■ Inadequate protein-energy intake (NI-5.3)
■ Increased energy expenditure (NI-1.1)
■ Increased nutrient needs (NI-5.1)
■ Malnutrition (NI-5.2)
■ Unintended weight loss (NC-3.2)
■ Swallowing difficulty (NC-1.1)
■ Altered GI function (NC-1.4)
■ Predicted / Food-medication interaction (NC-2.4 or NC-2.3)
■ Altered nutrient-related laboratory values (NC-2.2)
■ Food and nutrition-related knowledge deficit (NB-1.1)
■ Limited access to food or water (NB-3.2)
Nutrition Interventions for Case Patient
Adjust meals to a texture modified diet (ND- 1.2) to
ease pain from oral thrush and mouth sores by
recommending soft foods (prepared mashed, pureed,
or cooked until very soft).
Refer pt to another provider (ND-1.5) for treatment of
oral thrush, likely with antifungal medication.
Promote a general/healthful diet (ND-1.1) with small,
frequent meals to prevent further weight loss and
promote weight regain to achieve IBW of 184# or at
least UBW of 160-165#.
Nutrition Interventions for Case Patient
Refer pt to another provider (or community program
if necessary) (ND-1.5; ND-1.6) if necessary to
decrease alcohol intake & receive more education on
living with AIDS.
Instruction intended to lead to nutrition-related
knowledge. Purpose of nutrition education (E-1.1)
should be to improve pt’s food choices to improve PO
intake toward meeting EEN; minimize DNIs w/ current
medications; and stop excessive supplementation &
alcohol consumption.
Nutrition Interventions
■ Highly individualized: Very important to tailor
intervention to pt needs using clinical judgment &
collaborating w/ team of healthcare providers!
■ Energy/nutrient needs: NO specific nutrition therapy for
HIV/AIDS except for meeting additional energy, protein,
fluid, & micronutrient needs.
■ Specific diet/recommendations: Diet adjustments &
nutrition counseling often needed to manage HIV/AIDS
complications & comorbidities such as:
■ Cardiovascular disease/risk
■ Liver or renal disease (e.g., hepatitis B & C)
■ Diabetes, insulin resistance, and/or altered sex hormones
Nutrition Interventions
■ Provide adequate nutrition/
reduce or eliminate malnutrition
⬜
⬜
⬜
⬜
PRIORITY of treatment to prevent weight loss/wasting
necessary for body to properly process meds & nutrients
may significantly slow progression to AIDS
decrease disease severity, maintain immune fxn, improve
lifespan & quality of life
⬜ can be challenging to balance important health priorities
■ Minimize drug-nutrient interactions
⬜ many drugs need to be taken w/ regard to food
⬜ common HAART side efx of N/V/D, anorexia, dyslipidemia
⬜ potential interactions w/ alcohol, grapefruit, supplements
Source: "Position of the American Dietetic Association: nutrition intervention and human immunodeficiency virus infection." JADA 110.7 (2010): 1105-
Nutrition Interventions
■ Management of N/V/D
⬜ Small, frequent lower-fat meals w/ snacks
⬜ Replenish fluids & nutrients when lost
⬜ Avoid lying down within 1 hour of eating
⬜ Limit or avoid lactose, caffeine, & insoluble fiber
⬜ Nutrition supplements and medication as needed
■ Adjunct Therapies
⬜ Common Medications: antiemetic, antidiarrheal, appetitestimulating, lipid-lowering, antidiabetic, anabolic, & pain
⬜ Exercise: maintain/increase LBM, promote healthy BMI &
body shape, & promote CV health
Sources: http://coveville.com/how-to-get-rid-of-diarrhea/
Nutrition Care Manual
Nutrition Interventions
■ Education & Counseling
⬜
⬜
⬜
⬜
General nutrition & PA principles
Food safety & access issues
Meal preparation, timing, & content
Medical adherence & potential DNIs
⬜ Micronutrient supplementation
⬜ Body image & changes to body weight/shape
⬜ Other psychosocial issues
■ Referral to Other Providers
⬜ Last but NOT least...this is key to any plan of care
for HIV/AIDS patients!
Sources: http://www.school-counselor.org/topics/new-school-counselor.html
Nutrition Care Manual
Nutrition Support
■ Enteral nutrition (EN) & parenteral nutrition (PN) support are
both viable options for HIV/AIDS patients if needed.
■ Criteria for initiating either EN or PN remain the same as for
other disease states & ASPEN Guidelines should be followed.
■ “If the gut works, use it!” still applies here...even when PN has
been initiated, it is important to stimulate the gut regularly with
water & a little food if at all possible to prevent GI dysfunction &
reduce risk of bacterial translocation.
■ Catheter infection & refeeding syndrome are the primary risks
of NS but minimized with proper monitoring & adjustment.
⬜ Especially for highly immunocompromised HIV/AIDS patients,
additional sanitary precautions including the use of sterile water
may be needed to reduce risk of infection.
Nutrition Monitoring & Evaluation
■ Nutrition reassessments should generally be carried
out at least every 3-6 months in HIV/AIDS patients.
■ Treatment for this population is highly individualized, so F/U
may be appropriate sooner than 3 months depending on the
initial nutrition assessment, diagnosis, & intervention.
■ During reassessments, it is important to monitor:
■ Food intake
■ Body weight, distribution, & composition
■ Anthropometric measurements can help identify HALS even
when weight is stable!
■ Pertinent lab values
■ Medications
■ Supplements
Nutrition M&E for Case Patient
■ Monitor weight over next 2 months
■ Encourage 0.5-1 lb. weekly weight gain
■ Target weight 184 lb. (acceptable range is 166-202 lb.)
■ With changes and disease progression, monitor & evaluate:
■
■
■
■
■
■
Food intake
Lab values
Body composition
Medications
Supplements
Ensure that education is continual and appropriate
■ M&E should take place at least semiannually after initial F/U