Download 2008_NutritinalGuidlineforPLHA2008

Development of Nutritional Guideline for PLHIV
Contents
Objective of the Guideline
Target Users
Using this Guideline
Chapter 1: Introduction
Magnitude of HIV in Bangladesh
National Strategic Plan for 2004 – 2010 and Nutrition
Key Points
Chapter 2: Nutrition and HIV
Basic Concept of Nutrition
Nutrient Values of Some Common Foods Consumed in Bangladesh
Nutrition Situation in Bangladesh
Nutrition and HIV
Benefits of Nutrition Support
Key Points
Chapter 3: Support to adolescents and adults with HIV in Nutritional Care
Nutrition and Adults with HIV
Nutrition and Women with HIV
Nutrition and Injecting Drug Users with HIV
Nutrition and PLHIV Co-infected with Tuberculosis
Nutrition Management of Asymptomatic HIV Infection
Nutrition Based Symptom Management
Key points
Chapter 4: Support to HIV positive pregnant and lactating women
Nutritional Status of Pregnant and Lactating Women with HIV
Key points
Chapter 5: Support to HIV infected infants and children
Infants (Birth to 12 Months)
Children (1 to 10 Years)
Orphans and Vulnerable Children
Key Points
Chapter 6: Nutritional Care for PLHIV receiving ART
Importance of Supportive Therapies to ART
Herbal Remedies
Food–Drug Interactions
Balancing Food and Medication
Key Points
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Chapter 7: PLHIV and Food Security for Their Households
PLHIV and Food Security
Approaches to Food Security and HIV
Strategies for Food Security of Households with PLHIV
Key Points
Chapter 8: Nutrition Interventions for PLHIV
Nutrition Interventions for PLHIV
Nutritional Assessment and Dietary Counselling for PLHIV
Other Examples of Nutrition Interventions
Key Points
Chapter 9: Monitoring and Evaluation (M&E) of Nutrition Activities
Aspects of Monitoring and Evaluation in Nutrition Programs
Key Points
References
Annexes
1. Clinical Nutrition Assessment Tools
2. Nutrition Education Tools
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Development of Nutritional Guideline for PLHIV
Objective of the Guideline
The guideline provides practical recommendations for a healthy and balanced diet for
people living with HIV in Bangladesh. It aims to improve the nutrition situation of PLHIV
through care delivered through a variety of settings. It is applicable for people with HIV in
home-based care, community care, hospitals and other institutional settings, such as
hospices.
The food requirements of people with HIV are described and recommendations given on
foods and eating habits to meet these requirements. The guideline also explains how to
address the nutritional aspects of HIV-related conditions. Practical recipes using locally
available foods are suggested as well as some strategies to help ease some of the problems
people with HIV may experience.
The information contained in the guideline is compiled from a number of reputable
international sources and adapted for the Bangladesh context.
Target Users
The guideline consists of:
1) Key information and explanations (the main text) intended for use by:
• Health service providers and other extension workers as well as those involved at the
national and community level in the many different aspects of counselling and
home-based care
• Community-based organisations working with people with HIV who need
information for programming and counselling purposes.
• Planners in the health, social and nutrition services so they can develop local
guidelines for nutritional care and support for people living with HIV.
• International agencies that support national and community-based support
programmes for people with HIV in Bangladesh.
2) Summary sheets that can be used as handouts, listing the main points for each key topic.
The summary sheets and leaflets are specifically for use by people who are living with
HIV or who are caring for a person living with HIV, who want to be better informed.
The Annexes contain:
• Further technical information
• Forms to monitor food intake and weight
• Sources of literature and information on institutions providing support for people living
with HIV
Using this Guideline
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Although the recommendations in this guideline are generic, the general principles will be
relevant for most people living with HIV in Bangladesh. However, specific nutrition
recommendations will need to be adapted to the needs of individuals at the local
community.
In developing these recommendations, research findings and experience gained in a wide
range of settings have been incorporated. The development of this guideline has involved a
number of key stakeholders in HIV in Bangladesh including Government (NASP), UN
agencies (WFP, UNAIDS), other international agencies (ICDDR’B, FHI, Care and HKI) and
affected communities (Asha Alo Society, Muktar Akash and CAAP).
The technical content of this guideline was developed by Nutrition technical advisors from
the Albion Street Centre, Sydney Australia.
Once the guidelines have been finalised, a program for dissemination at national, district
and local levels needs to be developed. This program would include:
 Distribution of the guidelines to government, international and national organisations,
 Training workshops for field staff on the use of the guidelines in nutrition work with
people with HIV
 Development of educational aids such as brochures, posters, leaflets, fact sheets,
training materials, issue briefs, music and theatre activities and nutrition ambassadors.
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Chapter One: Introduction
Magnitude of HIV in Bangladesh
While the overall prevalence rate in Bangladesh remains low at less than <0.1% among the
general population (4), the prevalence rates among high risk populations such as injecting
drug users, migrant workers and sex workers is approaching 1% nationally(5). In some
regions in Dhaka the prevalence of HIV among IDU’s is nearly 9% (6).
The Sixth National HIV Serological Surveillance (2005) found that HIV among injecting drug
users in Central Bangladesh was 4.9%, this represents more than a 3 fold increase in
prevalence since 2001(5). The last UNAIDS update (2006) estimated that 11,000 adults (1549 years) were living with HIV by the end of 2006, irrespective of whether or not they had
developed symptoms of AIDS, including 3,100 women (15-49 years), and 310 children less
than 15 years. According to Government sources, 363 HIV positive cases were reported as of
December 2003, among them 57 developed AIDS and 30 have died. Bangladesh has laid a
solid foundation by recognising that HIV is an important public health challenge. It was the
first among the SAARC countries to formulate a national policy on HIV/AIDS (1995). Since
then, related policies and implementation frameworks with respect to HIV/AIDS have been
developed further. Efforts have been made to build strong partnerships among
Government, non-government organisations (NGO), and civil society.
National Strategic Plan for HIV/AIDS 2004 -2010 and Nutrition
Bangladesh is one of the few South Asian Association for Regional Cooperation (SAARC)
member countries which as integrated nutrition into it’s National, Strategy on HIV (7).
Nutrition support forms an important component of the Bangladesh ‘National Strategic Plan
for HIV/AIDS 2004-2010’. Integrating nutrition support has been identified as an important
activity under ‘Programme Objective 4: Provide care and support services to People Living
with HIV AND AIDS’ and also as a sub-component of Objective 4 titled ‘Provide care, support
and treatment to Children and their families’ (7).
The implementation of operational plan of the National Strategic Plan (NSP) is one of the
major responsibilities of NASP. NSP gives much emphasis on Treatment, care and support
services for people with HIV. NASP is playing a stewardship role as a central body to
coordinate HIV activities. NASP will arrange for technical assistance to develop a national
care and support strategy, including detailed strategies around HIV case management, VCT,
PMTCT, home based care etc. Technical professionals will develop protocols and standard
operation procedures (SOP) on the basis of international guidelines and best practice,
adapted for the Bangladesh situation. Priority guidelines include HIV & opportunistic
infection management; antiretroviral treatment; home care; PMTCT services; post exposure
prophylaxis; nutritional support; and spiritual counselling. NASP will develop the curricula
and IEC materials with technical assistance from a range of agencies.
In May 2007 a policy workshop was organized as a joint partnership between the
Government of Bangladesh, World Food Programme, Bangladesh and UNAIDS, Bangladesh
Office. The aim of the workshop was to strengthen advocacy for the role of dietary and
nutrition interventions as part of HIV prevention and Care, Support and Treatment (CST). A
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Development of Nutritional Guideline for PLHIV
secondary aim was to develop initial plans for implementing HIV nutrition intervention
partnership programs. One of the key outcomes from this meeting was to develop a
guideline on ‘Nutrition in Response to HIV’. WFP Bangladesh Country Office (CO) has taken
a lead role as a co-sponsor of the UNAIDS Division of Labour document(8) in the technical
area of ‘diet and nutrition support’, to develop ‘Nutrition Guidelines for PLHIV’ for
Bangladesh in collaboration with stewardship of NASP.
Key Points
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The incidence of HIV among the general population of Bangladesh is less than 0.1%
making it low HIV prevalence country.
At the end of 2006, it was estimated that there were 7,500 people living with HIV in
Bangladesh
The incidence of HIV among vulnerable groups, particularly injecting drug users is
much higher and in some areas is approaching 8%.
The current National Strategic Plan for HIV in Bangladesh was developed for the
period 2004 – 2010.
This plan integrates nutrition interventions as an important component of
comprehensive HIV care
Through it’s UNAIDS cosponsor mandate the World Food Programme is taking a lead
role in diet and nutrition support of PLHIV
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Chapter Two: Nutrition and HIV
Basic Concept of Nutrition
Nutrition is the study of how the body utilises the nutrients from food. These nutrients are
important to help the body stay alive and healthy, and are used for growth, development,
work, and other physical activities(2). Food habits are defined by the quantity, quality of
food consumed and the methods of obtaining, consuming and utilising food. Most food
habits are learned and passed on from one generation to the next. As individuals mature
and develop, experiences influence changes in some of these habits. Nutrition education
can also help to change food habits.
Food is important for everyone not only to keep physically healthy but familiar foods have
an important psychological component. Food reminds people of their childhood, home
country and strengthens societies, and as such has an important role in supporting cultures
and communities. When people eat well they often feel well.
On a biological level, food provides the energy and nutrients that our bodies need to:
• stay alive, move and work;
• build new cells and tissues for growth, maintenance and repair;
• Resist and fight infections.
When the body does not get enough food, it becomes weak and cannot develop or function
properly. Healthy and balanced nutrition means eating the right type of foods in the right
quantities to keep healthy, fit and promote independence.
Foods can be classified into three main groups according to the nutrients contained in the
foods.
1. Body-building foods
These foods contain protein which is used
by the body for growth, maintenance and
repair of body tissues. Foods in this group
include beans, peanuts, fresh milk and dairy
food, eggs, fish, chicken, beef, and other
animal meats.
Examples of body building foods
2. Energy Foods
Foods in this group are good sources of
carbohydrates or fats, which are used by
the body to provide fuel for physical
activity. Foods high in carbohydrates are
rice, wheat products (such as bread,
paratha, naan and chapattis), noodles,
Examples of energy foods
potato, sweet potato, sugar, honey, and
sugar cane, while those high in fat are coconut milk, cooking oil, animal fat.
3. Protective foods
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Development of Nutritional Guideline for PLHIV
These foods contain essential vitamins
and minerals which work with bodybuilding and energy foods in preventing
and fighting disease and illness. They
contain substances called micro-nutrients
which include vitamin A, iodine and iron
and are necessary for good health Foods
in this group are mainly vegetables and
Examples of protective foods
fruits, but there are some very important
animal sources as well. It is important to
note that these foods need not be expensive. Many cheaper alternatives of these foods
such as beans and pulses are also available.
A good nutritional status is when the body has enough and right kinds of food to meet its
requirements for proper functioning, growth, repair and maintenance of health. Individuals
need food to provide energy for work and to regulate body temperature. It is also required
to control body processes and to protect against disease and infections. In this way, food
not only maintains life but also influences the quality of life in people. Malnutrition is the
body's physical response to limited intake of food, in both quantity and quality. It can also
be the cause or result of chronic illness, such as diarrhoea.
The following table provides a basic summary of the nutritional value of particular foods and
recipes, and the contribution they make to an individual’s intake.
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Development of Nutritional Guideline for PLHIV
Nutrient Values of Some Common Foods Consumed in Bangladesh
Food
Food Item
1 cup boiled rice
1 chapatti
1 cup dhal
1 medium size Fish (120g)
1 egg
1 cup milk
1 medium banana
Recipe Item2
1 serve mixed vegetable/ bean soup
1 serve mixed vegetable/ fish soup
1 serve Sobuj bhath
1 serve Sobuj ruti
1 serve Sajna bhorta
1 serve Mixed vegetable pitha
1 serve coconut egg vegetable curry
1 serve mixed vegetable bean salad
Contribution to Estimated Daily
Energy Requirement1
Contribution to Estimated Daily
Protein Requirement
240 Kcal (10%)
130 Kcal (6%)
215 Kcal (9%)
150 Kcal (7%)
75 Kcal (3%)
170 Kcal (7%)
75 Kcal (3%)
4g (5%)
4g (5%)
17g (20%)
27g (32%)
7g (9%)
9g (11%)
2g (2%)
B-group vitamins
B-group vitamins
B-group vitamins, vitamin c, iron
Some B-group vitamins
B-group vitamins, vitamin A, iron
B-group vitamins, vitamin A, calcium, zinc
Vitamin C, B-group
200 Kcal (9%)
300 Kcal (13%)
420 Kcal (18%)
325 Kcal (14%)
220 Kcal (10%)
532 Kcal (23%)
550 Kcal (24%)
130 Kcal (6%)
9g (11%)
12g (14%)
14g (16%)
10g (12%)
5g (6%)
15g (18%)
14g (16%)
6g (7%)
Vitamin A, B-group Vitamins, Iron
Vitamin A, B-group Vitamins, Iron
Vitamins A, E, C, and B-group, Iron
Vitamin A and B-group, Iron, Calcium
Vitamin A, Iron
Vitamin A, Vitamin C, B-group vitamins
Vitamin A, Vitamin C, B-group vitamins, Iron
Vitamin A, Iron, B-group vitamins, Vitamin C
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Micronutrients
Based on PLHIV adult energy requirement estimated to be 2310Kcal (2100 + 10% asymptomatic HIV Infection), estimated daily protein requirement 85g (15% of total energy
intake)
2
All recipes contained in this example are sourced from Bhattacharjee Et.al. 2007 9
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Nutrition Situation in Bangladesh
Despite the significant improvement in the overall health and nutritional status of the
Bangladeshi population over the past ten years there are a number of important nutritional
problems frequently experienced by the Bangladesh population (10). Problems such as
malnutrition, micronutrient deficiencies (particularly Vitamin A, iodine and iron), low birth
weight, stunting and wasting affect a large proportion of the population, particularly
vulnerable groups such as women and children (9).
Nutrition and HIV
The impact of HIV extends well beyond the impact of the virus on the immune system. The
range and complexity of social and biological factors influenced by HIV have a progressive
impact on the health, nutritional status and well being of someone living with, and those
affected by HIV (11). In terms of physical health, PLHIV can experience a number of
symptoms caused by HIV and other complications often related to antiretroviral therapy
(ART) (12, 13). These problems increase the frequency that someone living with HIV
experiences ill health, which can often lead to a reduced ability to work, reduce longer term
productivity and ability to earn an income (14). This reduced productivity and income
earning capacity is one of the most devastating consequences of HIV and threatens the long
term food security of not only the individual but also those they support.
Figure 2.1: The cycle of malnutrition and infection in the context of HIV(1)
Poor Nutrition
(Weight loss, muscle wasting,
weakness, micronutrient deficiency)
Increased Nutritional Needs
(due to malabsorption and
decreased intake)
HIV
Impaired Immune System
(poor ability to fight HIV and
other infections)
Increased Risk of Infection
(e.g. Gut infections, TB leading too
faster progression to AIDS)
Among infected individuals, HIV contributes to and is affected by nutritional status.
Consequences of HIV infection include inability to absorb nutrients from food, changes in
metabolism, and reductions in food intake due to HIV-related symptoms. In turn, poor
nutrition increases the vulnerability to, and the severity of, opportunistic infections. Poor
nutrition can also reduce medication efficacy and adherence, and can accelerate the
progression of disease.
HIV has a broad reaching impact on society experienced at an individual, family and
community level. This is primarily experienced through a number of areas:
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Development of Nutritional Guideline for PLHIV
1. Food Access – this includes issues such as access to food supply and other important
services such as education, transport and health care. As PLHIV experience declining
health access to these services can become limited.
2. Employment and Income Security –the declining health experienced by many PLHIV,
often reduces their ability to find work and earn an income. This is made worse as
medical costs increase, limiting the individual’s income available to buy food (15).
3. Mental Health – mental health problems such as depression, social isolation and anxiety
are more common among PLHIV (16). This may be caused by disclosure of HIV status and
other issues such as drug use or sexuality, difficulty in adjusting to the HIV diagnosis,
rejection by family or friends as a result of disclosure, and as a result of stigma and
discrimination commonly experienced by many PLHIV in most communities. These have
a potential impact on reducing motivation for meal preparation, reducing appetite and
food intake.
4. Skills and Education - From an individual perspective, many PLHIV may have poor
knowledge and understanding of purchasing and preparing nutritionally adequate food,
or other important issues such as food hygiene.
5. Personal Beliefs – These have an important influence in determining which foods are
acceptable and which should be avoided. These beliefs may come from the media,
family, peers and other individuals. Often PLHIV receive misinformation from media,
unscrupulous or untrained health care providers, family, friends or peers about ‘miracle
food’ or ‘nutritional supplements’. Often these treatments are expensive and have little
or no effect on improving health, and sometimes may impact on HIV treatment. Beliefs
about food and diet may have a significant influence on the success of nutrition
education and dietary counselling. It is important that nutrition educators recognise
these individual beliefs when planning any type of nutrition intervention (11).
There is a close relationship between an individual’s nutritional status and their immune
system. Similarly, declining immune function, as is experienced in HIV infection, has both a
direct and indirect impact on overall nutritional status. The following points outline common
biological problems contributing to poor or declining nutritional status.
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Higher Energy Needs – it is estimated that PLHIV without any symptom require an extra
amount of energy from food that is about 10% higher than the energy requirements of
the general population. This extra energy requirement is due to the repair of the
immune system as a result of HIV, and the additional burden HIV places on the body(17).
Gastrointestinal Problems – HIV infects nearly every cells in the body, none more so than
the cells of the gastrointestinal system. This has a significant impact on the body’s
ability to digest (break down) and absorb nutrients from food. This means that even if
an individual can maintain a healthy intake of nutrients the body cannot digest and
absorb the available nutrients as efficiently. Chronic weight loss and malabsorption in
HIV is often related to gastrointestinal diseases which is a cause of severe diarrhoea (18,
19).
Other infections – as disease progresses in HIV, people living with the disease can
become more vulnerable to other opportunistic infections. These infections have the
potential impact of increasing nutritional requirements and reducing an individual’s
desire or ability to eat.
Symptoms - such as diarrhoea, nausea and vomiting can be commonly experienced by
many PLHIV. As immune function declines all parts of the gastrointestinal system
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Development of Nutritional Guideline for PLHIV
become more susceptible to a range of disorders and infections. Infections such as
Candida Albicans (candidiasis) can infect the mouth and throat making chewing and
swallowing painful and difficult. These infections also have effect of reducing appetite
and sometimes cause nausea and vomiting. Other infections can also cause moderate to
severe diarrhoea.
Benefits of Nutrition Support
Nutritional interventions have the potential to promote the nutritional status, psychological
well-being, self-esteem and a positive outlook for people and their families living with and
affected HIV. Healthy and balanced nutrition should be one of the goals of nutrition
interventions and care for people at all stages of HIV infection. Figure 2.2 outlines the
relationship between improved nutritional status and HIV. An effective program of
nutritional care and support will improve the quality of life of people living with HIV, by:
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maintaining body weight and strength,
replacing lost vitamins and minerals,
improving the function of the immune system and the body’s ability to fight infection
extending the period from infection to the development of advanced HIV disease,
improving response to treatment; reducing time and money spent on health care,
keeping HIV-infected people active, allowing them to take care of themselves, their
family and children, and
keeping HIV-infected people productive, able to work, grow food and contribute to the
income of their families(2).
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Development of Nutritional Guideline for PLHIV
Figure 2.2: Relationship between good nutritional status and HIV(2)
Good Nutrition
maintaining body weight
Stronger Immunity
and resistance to infections
Eating Well
and good appetite
Slower HIV Disease Progression
and reduced illness
Key Points
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Food and nutrition is more than the physical health of our body, it is also an
important part of our mental health and social systems
Foods can be categorised under three groups energy foods, body building foods and
protection foods, each group is equally important in maintaining good physical health
HIV has a devastating impact on not only the physical health of the body but also the
social determinants of good nutritional status
Social factors include poor food access, lack of employment, mental health problems,
lack of skills and education, and personal beliefs
Biological factors affecting nutritional status in HIV include higher energy needs,
gastrointestinal problems, other infections and nutrition related symptoms
There are a number of individual and health care benefits of integrating nutrition
interventions as part of comprehensive HIV care
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Chapter Three: Support to HIV adults with Nutritional Care
Nutrition and Adults with HIV
HIV has significant nutrition-related implications and consequences for adults.
There is a close relationship between an individual’s nutritional status and their immune
system. Poor nutritional status has a detrimental effect on immune system development
and function. Similarly, declining immune function, as is experienced in HIV infection, has
both a direct and indirect impact on overall nutritional status.
Energy Requirements - PLHIV have a resting metabolic rate (RMR) (the amount of energy
people use when people are resting) that is around 10% higher compared to HIV negative
adults. RMR can increase by 100% in advanced stages of HIV infection or during periods of
opportunistic infections (20-25). This chronic increase in energy expenditure is a significant
contributor to weight loss among PLHIV. This weight loss may occur despite an individual
maintaining their usual food intake after acquiring HIV, and during all stages of the disease.
This can increase to as much as 20 – 50% during periods of illness or infection(17).
Protein Requirements - There is a common belief that PLHIV have a higher requirement for
dietary protein (body building foods). Despite some research showing improvements in
muscle stores (or Lean Body Mass) (26) and total body weight (27, 28) with increased
protein intake, further research is required to determine if PLHIV have additional protein
needs compared to those without HIV. In line with WHO recommendations, protein should
provide at least 10-12% of total energy.
Many PLHIV in Bangladesh have pre-existing protein-energy malnutrition (PEM), resulting
from inadequate intake of food. This type of deficiency is not just caused by lack of protein
in the diet but lack of total energy or kilocalories from food. Therefore, foods and meals
must be balanced to contain adequate energy as well as protein. One of the perceived
difficulties of body building foods, such as animal protein, milk and eggs, is that they are
often relative expensive and are sometimes difficult to store safely. There are a number of
relatively inexpensive body building foods such as dried beans, nuts and pulses.
Micronutrient Requirements – many of the micronutrients are found in protective foods.
Research has shown that micronutrients play an important role in HIV infection.
Micronutrient deficiencies are common among both adults and children living with HIV(29)
(30) (31) (32). Ideally, an adequate micronutrient intake should be achieved through
consuming a diverse range of foods rich in micronutrients. Where available, fruits,
vegetables and/or fortified food should be eaten daily. Further research is required to
establish the required intake of individual micronutrients to maintain normal nutritional
status in PLHIV at different stages of the disease, for those who are not currently receiving
antiretroviral treatment and those who are on treatment (33).
Nutrition and Women with HIV
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The ‘Feminisation’ of HIV is a growing well know topic that has already had a heavy toll in
the lives of women. In terms of nutrition, women are more vulnerable to the impact of poor
nutrition because of its biological vulnerability and marginalized position in the patriarchal
society. In general women are vulnerable to food insecurity, and when they become HIV
positive, it heightens their susceptibility to develop advanced disease. This relationship is
particularly important to understand as women are physiologically, economically, and
culturally more at risk of HIV infection than men. Thus women vulnerability aspect and their
accessibility issue to nutrition care should be taken in to special consideration prior to
design any nutrition intervention program.
Women often experience a ‘double burden’ as they tend to be primary caregivers and
providers of food in families and communities. When women are unwell and unable to meet
the basic needs of family and community, severe food insecurity may result. In addition to
the physical symptoms of HIV, women may also have to combat discrimination and lack of
social support that is commonly associated with HIV infection (34). Gender inequality: in
many regions of the world distinct differences exist in terms of accessing services between
men and women. This includes equal access to basic needs including food and
opportunities such as land ownership, education and employment
Dietary recommendations and nutrition counseling for women with HIV are similar to those
for the general population (35, 36) However due to the social and cultural issues which
commonly affect women’s access to adequate nutrition, gender specific programs should be
considered.
Nutrition and Injecting Drug Users with HIV
In Bangladesh, HIV has the biggest impact among injecting drug users (IDU). This group also
faces a number of significant challenges that further compound issues such as poor food
intake and nutritional status. IDU are far less likely to access care and treatment as
discrimination and stigma from health care workers is common (37). This has an important
impact on individual’s willingness to access health care services. IDU as a group are more
likely than the general population to be living in poverty, and experience food insecurity.
The nature of addiction, seeking and using drugs may take priority over tasks such as food
preparation (38, 39). As seen in many regions of Bangladesh IDU are at greater risk of
homelessness and mental health problems such as depression, anxiety and psychosis (40,
41).
Research has shown that PLHIV who inject drugs are more likely to be underweight than the
general population (39, 42). Micronutrient deficiencies are common in IDU, regardless of
HIV status. Injecting drug use is often associated with decreased nutritional quality of diet
and increased vulnerability to nutrient deficiencies (38, 42, 43). This may be attributed to
nutritional insufficiency of diet, malabsorption, metabolic abnormalities or increased
nutritional requirements (42).
Also IDU frequently experience a range of symptoms relating to drug use that although
separate to HIV often compound the problem of malnutrition among this group. Issues such
as dry mouth, gum disease, dental decay and oral problems are perpetuated by poor oral
hygiene and declining immune function (38). In planning and delivering services to this
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Development of Nutritional Guideline for PLHIV
group it is important to ensure an empathetic and non-judgmental attitude from health care
workers to avoid further isolation of IDU from health services.
PLHIV Co-infected with Tuberculosis
TB is a big public health problem in Bangladesh with more than 610000 people living with
the disease, this is the sixth highest incidence globally (44). TB is a common problem among
PLHIV, particularly those with advanced stages of disease with declining immune function.
Studies have shown that the risk of developing TB for PLHIV is increased if they have poor
nutritional status (45, 46). This is also common among populations who are forced to live in
confined and unventilated areas, which is common for many PLHIV living in Bangladesh.
People with TB are often already stigmatised as a result of this disease. Those with both TB
and HIV can be doubly stigmatized and therefore may reduce the PLHIV’s access to food.
Malnutrition has been identified as an important factor in the clinical progression and
response to treatment of both TB and HIV (47). If PLHIV are also infected with TB, weight
loss is very rapid (47, 48). Malnutrition is associated with early death in PLHIV co-infected
with TB (49). Pulmonary TB can make breathing difficult during acute illness and lead to
fatigue and reduced food intake, poor appetite and nausea are also common. TB increases
a person’s energy requirements and leads to weight loss, especially when dietary intake is
inadequate.
Generally, energy requirements will be 20-30% higher among people with both HIV and TB
infections (50). Given the various symptoms experienced by people with TB interventions
may also need to include components of texture modification and/or supplementary
feeding may be required depending on individual symptoms. Supplement the diet with high
energy foods or supplement drinks when commencing TB treatment. Nutrition interventions
using energy and protein supplements initiated at the same time as commencing antituberculosis drugs significantly improved lean body weight and physical function in a study
of patients with wasting (51). Providing food assistance in resource poor settings as an
incentive to complete TB treatment can improve compliance. Nutrition counseling is
recommended to accompany any food assistance programs for people with TB infection, to
improve health outcomes and treatment response (50).
Nutritional Management of Asymptomatic HIV Infection
The following food based recommendations for asymptomatic PLHIV are collated from a
number of sources.
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Being aware of the importance of food and nutrition
PLHIV should eat diverse range of foods from each food group
Use fats and oils as well as sugar and sugary foods
Minimise loss of nutrients through cooking
Drink plenty of clean and safe water
Promotes regular exercise
Promote good oral and dental hygiene
Reducing or stop alcohol and illicit drugs
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Development of Nutritional Guideline for PLHIV
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Ensure good food quality and safety of food for PLHIV
Being aware of the importance of food and nutrition(2)
It is important for the individual to take personal responsibility for their health and become
an active participant in their health care. A good place to begin this care is to learn about
the importance of body building foods, energy foods and protective foods on the body's
functioning and on processes such as the immune system, growth and repair. Prevention is
better than cure. The earlier a person starts to eat a healthy and balanced diet, the more
they will stay healthy. Once weight has been lost it may be difficult to regain it because of
tiredness and lack of appetite. It is important to raise awareness about the importance of
food and nutrition and the link to immunity and good health in PLHIV.
PLHIV should eat diverse range of foods from each food group (1, 2, 11, 50, 52-55)
This involves eating a variety of foods regularly, ensuring a steady source of nutrition and
assists in maintaining a good appetite. Meals may vary from frequent regular snacking to
substantial meals at certain times of the day. The types of foods that should be eaten daily
include:
 Energy providing foods: these are high in carbohydrates and are usually the staple of the
meal. They provide energy to work and live and help the body maintain a healthy
weight. These foods are relatively cheap and should make up the largest part of the
meal. Recommend eating a staple at every meal.
 Body building foods: these foods high in protein and minerals. They help to build up
muscles and bones and to repair the body when ill. They will help strengthen the
immune system. These foods should be eaten at least 1-2 times per day or as often as
the client can afford them, although it is important to consider cheaper alternatives such
as beans and pulses.
 Protective foods: these foods are foods high in vitamins and minerals. They help to keep
the immune system strong and keeps the body functioning. These foods are especially
important for people living with HIV/AIDS to fight off infection.
Use fats and oils as well as sugar and sugary foods(2): Fats, oils and sugar are good sources
of energy and can help one gain body weight, which can be particularly important for PLHIV.
They also add flavour to food, which can help improve appetite. Fats and oils play an
important part in a healthy and balanced diet. Even small amounts of these foods provide
lots of energy.
Minimise loss of nutrients through cooking(2): Since the vitamin content of food can be
damaged during cooking, it is better to boil, steam and fry vegetables for a short time only.
Boil vegetables in a little water and use it afterwards for cooking as it contains considerable
amounts of vitamins and minerals. Vegetables will lose some of their vitamins and minerals
if soaked for a long time.
The skins and kernels of grains and legumes contain vitamins, in particular of the B-group.
Processed refined grains have lost many of their vitamins, minerals and proteins so whole
grains such as brown bread and unrefined cereals are better sources than white bread and
17
Development of Nutritional Guideline for PLHIV
refined cereals. Fortified cereals and bread are preferred because of their higher vitamin
content. Micronutrient supplements can be useful but cannot replace eating a balanced and
healthy diet.
Drink plenty of clean and safe water (2): Water is important for life and is necessary every
day. A person needs about eight cups of fluid per day. When it is very hot, while working,
sweating or suffering from diarrhoea, vomiting or fever, a person needs to drink even more
to replace the water that has been lost. Water unless bottled, should be boiled for at least
ten minutes and stored in a clean container (see advice on food hygiene). In addition to
drinking clean water, fluid can also come from juices, soups, vegetables and fruit as well as
meals that have gravy or sauces. Avoid drinking tea or coffee with a meal, as this can reduce
appetite as well as some of the absorption of some nutrients from food.
Alcoholic drinks remove water from the body and should therefore be consumed only in
limited amounts. They can also interfere with the action of medicines.
Promotes regular exercise (2): There are many benefits attributed to regular aerobic and
anaerobic exercise. Aerobic exercise involves more endurance type activities such as brisk
walking, swimming, cycling and jogging. It is recommended that an individual start this form
of exercise in small increments, gradually increasing the frequency to 3 - 4 times per week.
Anaerobic or resistive exercise is affective for increasing the lean body mass. If performed
regularly, up to 3-4 times per week this form of exercise may also have benefits for the
immune system, sleep, stress relief and appetite.
Promote good oral and dental hygiene (2): Dental hygiene is also important in maintaining
good health. Minor problems in the mouth can quickly develop into painful lesions,
affecting oral nutritional intake. Infections such as gingivitis are more common in HIV and
are easily preventable with regular brushing and where possible routine checkups with the
dentist.
Reducing or stop alcohol and illicit drugs(2): drugs such as alcohol, tobacco, marijuana,
opium and amphetamines can all affect nutritional status. Drugs such as nicotine (found in
cigarettes) can reduce appetite and reduce the body's ability to do exercise and therefore
should be avoided. The effect of other recreational drugs on the immune system is unclear,
but other drugs such as heroine and the amphetamines may reduce appetite and increase
the body’s requirements for energy, protein, vitamins and minerals.
Ensure Good Food Quality and Safety of Food for PLHIV: Food can be contaminated with
harmful bacteria and viruses (called germs), which produce poisonous toxins. A person
eating this food may be infected by the germs and made sick from the toxins. Because HIV
affects the immune system and the body's resistance to disease, people with HIV/AIDS are
more vulnerable to germs and should be careful to avoid eating contaminated food. If they
get food poisoning it can cause diarrhoea, nausea and vomiting that can lead to weight loss.
The immune system can then become even weaker, which will lower the body's resistance
to future infection. Secondary infections, transmitted through food and water, contribute
significantly to the morbidity and mortality of HIV infected persons. Most food poisoning
can be prevented by following some basic rules of hygiene. Food hygiene measures have
two aims: i) to prevent contamination in food preparation areas; and ii) to prevent germs
18
Development of Nutritional Guideline for PLHIV
from multiplying in food and reaching dangerous levels. The food safety and hygiene
practices suggested below will achieve both these aims and ensure maximum protection
from the risk of harmful germs.
19
Development of Nutritional Guideline for PLHIV
Nutrition Based Symptom Management
Many PLHIV experience a range of symptoms associated with HIV or sometime the
treatment of HIV the following table provide a summary of strategies for managing HIV
symptoms that have a potential impact on the individual’s nutritional status.
Symptom
Unplanned Weight loss
and HIV associated
muscle wasting
Nutrition Strategies
Encourage good intake of energy and body building foods
Consider cheaper alternatives for body building foods
Encourage intake of smaller but more frequent meals
Choose foods with high nutritional value rather than nutrient
poor foods
Add ingredients to enrich foods so they have greater nutritional
value
Encourage snacking between meals
Increase serving sizes of meals and snacks
Avoid foods with little nutritional value
Diarrhoea – mild (Less
than 6 motions a day)
Encourage good intake of energy and body building foods
Encourage intake of smaller but more frequent meals
Suggest intake of fats as tolerated
Increasing soluble fibre, found in rice and pulses may help
Try intake of some fermented foods such as yoghurt
Diarrhoea – severe
(more than 6 motions,
often large volume and
watery)
Encourage good intake of energy and body building foods
Encourage intake of smaller but more frequent meals
Ensure intake of 3 – 4L clean safe water, consider using Oral
Rehydration Formula (ORL)
Temporarily reduce fat intake
Temporarily reduce intake of fibre containing foods
Temporarily reduce intake of dairy foods
Try intake of some fermented foods such as yoghurt
Small amounts of foods such as ripe banana, coconut water and
dilute juices may help
Avoid caffeine containing foods
Nausea and vomiting
Avoid strong odours
Choose foods with high nutritional value rather than nutrient
poor foods
Add ingredients to enrich foods so they have greater nutritional
value
Take meals outside or in pleasant environments
Try salty crackers or ginger foods to reduce nausea
Cold foods may be better tolerated than hot foods
20
Development of Nutritional Guideline for PLHIV
Symptom
Poor appetite
Nutrition Strategies
Eat more when hungry
Choose foods with pleasant aroma to stimulate appetite
Add ingredients to enrich foods so they have greater nutritional
value
Eat meals with family and friends
Difficulty in chewing
and swallowing
Suggest enriching liquids such as drinks and soups that are
usually better tolerated
Frequent small regular meals and snacks every 2 – 3 hours to
maintain energy intake
Utilise high energy, protein containing foods and liquids to
supplement nutritional intake
Avoid spicy and sour foods that may irritate painful areas
Rinse mouth with plain or salty water or brush teeth and tongue
after eating to reduce residue food left in the mouth
Use straws and spoons to avoid painful areas in the mouth
Use ice or oral anaesthetic to numb painful areas
Avoid low energy or ‘diet’ foods with limited nutritional value
Key Points
The key points of this section include:

During asymptomatic infection PLHIV energy requirements increase by 10%, this
can increase by 30 – 50% during periods of illness or infection


Protein requirements are not increased during asymptomatic HIV infection.

Some adult groups are more vulnerable to malnutrition, these include women,
injecting drug users and people with HIV/TB co-infection

It is currently recommended that PLHIV aim to met a recommended daily intake of
all micronutrients
General nutrition recommendations for asymptomatic PLHIV include:









Being aware of the importance of food and nutrition
PLHIV should eat diverse range of foods from each food group
Use fats and oils as well as sugar and sugary foods
Minimise loss of nutrients through cooking
Drink plenty of clean and safe water
Promotes regular exercise
Promote good oral and dental hygiene
Reducing or stop alcohol and illicit drugs
Ensure good food quality and safety of food for PLHIV
Chapter Four: Support to HIV Positive pregnant and lactating women
21
Development of Nutritional Guideline for PLHIV
Nutritional Status of Pregnant and Lactating Women with HIV
Dietary recommendations and nutrition counselling for women with HIV are similar to those
for other adults living with HIV (35, 36). However as discussed in the previous section,
woman face many challenges in maintaining a good nutritional status due to the social and
cultural issues which commonly affect women’s access to adequate nutrition. Poverty and
discrimination may prevent women from accessing health services including sexual and
reproductive health, antenatal care, PMTCT and ART (34), all of which can potentially
improve nutritional outcomes for women.
Pregnant women who are HIV positive are often diagnosed at early stages of HIV infection,
and therefore are less likely to be experience signs of advancing disease. While low birth
weight is common among children born to HIV infected mothers in resource poor settings, it
is not entirely clear whether HIV itself is responsible for the increased risk of low birth
weight or whether there are other factors involved. However, evidence from developing
countries indicates that children born to HIV infected mothers often suffer from poor
growth. It has also been observed that malnourished mothers are likely to give birth to low
birth weight (LBW) infants who are more susceptible to disease and premature death, (56)
Nutritional requirements increase during pregnancy and lactation, independent of HIV
status. There is still much to be learned about the relationship between HIV infection,
nutritional intake, short and long term health of pregnant and lactating women, and birth
outcomes. However a women’s nutritional status before and during pregnancy will influence
the health and survival of both mother and child (35, 57-59). Malnutrition is associated with
increased risk of MTCT (35).
Micronutrient supplementation in pregnant women is known to be beneficial in protecting
against adverse pregnancy outcomes among HIV infected women (36, 60, 61). Anemia (iron
deficiency) affects more than half of all pregnant women in resource limited settings and is
more common and severe in HIV–infected women (35) see appendix A2.1 for WHO
supplementation recommendations. Vitamin A supplementation (10 000 IU) is associated
with significantly improved birth weight (35, 59-63).
Counselling is recommended to meet energy and nutrient requirements for weight gain in
pregnancy and prevent nutritional depletion (35). Two keys aims are to prevent anaemia
and other micronutrient deficiencies (35, 59). It is also recommended that gender specific
or sensitive programs be developed that especially target female headed households
without family support and encourage women’s participation program matters including
governance (64, 65).
Key Points





Women who are HIV positive face many challenges in maintaining a good
nutritional status
Nutritional requirements increase as a result of HIV, pregnancy and lactation.
Malnourished mothers are more likely to give birth to low birth weight infants, and
risk of HIV transmission is greater.
Micronutrient supplementation has shown to be beneficial in protecting against
adverse outcomes in pregnancy
22
Issues relating to gender should be considered in all programs delivering care for
PLHIV.
Development of Nutritional Guideline for PLHIV
Chapter Five: Nutritional Support to HIV Infants and Chilren
Infants (birth to 12 months)
Wasting and stunting in children living with HIV is common (66). Such growth failure or low
muscle mass in children is associated with a high risk of death. Height in children has been
suggested as an important predictor of survival in HIV infected children (67-69). Low birth
weight and stunting are also common among children born to HIV infected mothers. HIV
negative children with an HIV infected parent are at higher risk of malnutrition due to
heightened susceptibility to food insecurity resulting from HIV infection.
The precise mechanism of malnutrition in children with HIV is not known. Factors similar to
that experienced by adults appear to contribute to child malnutrition including, inadequate
energy intake, malabsorption and increased energy expenditure, and food insecurity.
ART can assist children gain weight especially when adequate food is available. WHO
guidelines for treatment of infant and child malnutrition are recommended accounting for
the increased energy requirements in HIV.
Infants born to HIV positive mothers are more likely to be malnourished (LBW and postnatal
growth) (70-73) and generally malnutrition is associated with greater than 50% of child
deaths (56, 74). Severe wasting is a common clinical presentation of a child living with HIV
(75). Adolescent girls are at higher nutritional risk than boys particularly if they are pregnant
and younger adolescents are at higher risk than older ones (76). Pregnant adolescents with
HIV are at particularly high nutritional risk (76).
Prevention of Mother-To-Child Transmission (PMTCT) and Infant Feeding
Postnatal HIV transmission rate is estimated to be 15%-20% for prolonged breastfeeding
(about two years) (77-79). This can be reduced by approximately 5% by cessation of
breastfeeding at 6 months (i.e. mixed feeding in the first 6 months) and by half with
exclusive breastfeeding for 6 months with rapid cessation (77-79). Risk factors influencing
the outcomes include: low maternal CD4 count; high maternal viral load; recent maternal
HIV infection; duration of feeding; conditions of the breast/nipples; oral thrush in the infant;
and, mixed feeding (77-80). ART can reduce viral load in breast milk (81).
For many lactating mothers with HIV the choice of whether to breast feed or use
replacement feeding is not an easy one. There are a broad range of issues that need to be
considered in making an informed choice. Some of these factors include stigmatization (not
breastfeeding may signal the mother’s HIV status) and disclosure of HIV status (82),
psychological, social and cultural factors; the financial costs of replacement feeding; risk of
becoming pregnant again (75, 79, 83); access to voluntary HIV testing and counselling (VCT)
(83); levels of knowledge of mothers and health care workers (75) about replacement
feeding; illiteracy, and, religion.
23
Development of Nutritional Guideline for PLHIV
Safe replacement feeding is difficult to achieve due to infections of breast-milk substitutes,
and the inability of the substitutes to meet the infant’s nutritional requirements (79).
Unsafe replacement feeding has serious morbidity and mortality risks (77, 81, 84). There are
also other barriers to safe replacement feeding: the cost of the substitutes and access to a
safe and regular water supply.
For HIV positive women with infants, the United Nations (UN) (WHO, UNICEF, UNAIDS)
guidelines state “when replacement feeding is acceptable, feasible, affordable, sustainable
and safe, (AFASS) avoidance of all breastfeeding by HIV-infected mothers is recommended.
Otherwise, exclusive breastfeeding is recommended during the first months of life” (3, 79).
Use replacement feeding for at least 12 months only in ideal situations (AFASS). Introduce
safe complementary foods at about 6 months (59, 79, 85). If replacement feeding is not
AFASS, it is strongly recommended to have exclusive breastfeeding for the first 6 months
(77-79). At around 6 months, cessation of breastfeeding and rapid (2 days to 3 weeks)
weaning is recommended (59, 77-79). Further recommendations are available from WHO
(86))
Children (1 to 10 years)
Less is known about the relationships between children’s nutrition and HIV than for adults.
It is important to point out that traditional risk factors for child malnutrition among non-HIV
infected children, such as insufficient food intake and diarrhoea are also major contributors
to poor growth in HIV-infected children. Studies of children have shown that lean body mass
declines over time, while measures of fat stores remain constant. Practitioners often report
that early nutritional intervention in children is far more effective than waiting to intervene
until the later stages of HIV disease. Like adults, children with advanced HIV infection often
experience wasting syndrome and frequent infections and disturbed growth. Unlike adults,
the additional nutritional demands associated with growth mean that the effects of HIV are
often more devastating for children than adults.
Children experiencing growth failure should be targeted for overall healthcare, and the
cause of their growth failure determined and addressed, i.e. treatment of opportunistic
infections (75). Current recommends are that severely malnourished HIV-infected patients
be treated like others irrespective of their HIV status when resources permit (76) It is
recommended to treat malnourished children in the community or hospital setting (87, 88).
Effective community treatment for severe malnutrition is ready-to-use therapeutic food
(RUTF) until they have gained weight (87). There are a number of WHO resources providing
guidance on malnutrition (59, 87-89).
Orphans and Vulnerable Children
Globally, 15.2 million children under 18 have lost one or both parents because of HIV (87).
Although most of the children orphaned by HIV live in sub-Saharan Africa (82%) (90),
however Asia has twice as many orphans (due to all causes) (90). OVCs are at increased risk
of malnutrition and illness (90). This is due to numerous factors including economic
24
Development of Nutritional Guideline for PLHIV
hardship, lack of love, attention and affection, increased abuse, risk of HIV infection, stigma,
discrimination and isolation (90).
OVC households are more likely to be poor and food insecure (91, 92). Commonly unmet
needs in households with OVC are: education, food, medical care and clothes (92, 93). Other
issues included not being about to attending health care appointments, assisting with
educational support and development needs, and being unable to provide adequate care
when child is sick (93).
Key Points
 Wasting and stunting among children with HIV is common
 Growth and height have been identified as important predictors of survival of
children with HIV
 The choice to either breast feed or use replacement feeding is a difficult one,
influenced by a broad range of factors.
 Current guidelines on infant feeding and HIV are available from WHO(3)
 Children who are OVC tend to be more at risk of food insecurity, illness and
malnutrition, and also have less access to education and other basic needs
25
Development of Nutritional Guideline for PLHIV
Chapter Six: Nutritional Care to PLHIV with medication
Importance of Supportive Therapies to ART
Though good nutrition can help maintain and improve the quality of life of PLHIV, it is not
sufficient on its own. Prevention and proper treatment of HIV related infections is important
to avoid weakening the nutritional status further. ART is an important part of HIV care as it
reduces overall viral load and the rate at which the body's immunity is destroyed.
Despite the benefits of ART, it has been well documented that many people who are
receiving ART experience a range of short and long term side effects. The effect of dietary
strategies to maximise ART tolerance and adherence to ART is not well researched. In
clinical practice, Nutritionists report that PLHIV experience symptomatic relief from dietary
and lifestyle changes. Lifestyle changes may include eating regular meals, taking medication
with or without meals as recommended or eating different types of foods to reduce the side
effects of ART.
Short and long term side effects of ART include:
 Unplanned weight change
 Changes in taste and smell
 Reflux, bloating and other gastrointestinal changes
 Nausea and vomiting
 Poor appetite
 Diarrhoea
 Metabolic complications including increases in blood fats (a risk for heart disease),
Diabetes, and possibly weakening of the bones.
Nutritional therapy can assist in the management of each of these side effects, thereby
enhancing tolerance and adherence to ART. A lack of food is often mentioned as the most
likely cause of non-adherence to ART in developing country settings (94). Increasing access
to ART may be of limited benefit if people lack access to safe water or food.
Herbal Remedies
A large number of PLHIV use traditional medicine and herbal therapies as part of their
treatment of HIV. It is important to recognize that many of these therapies are not
supported by any scientific evidence as to whether they are effective or their interactions
with other conventional medicines, particularly ART. PLHIV should be encouraged to discuss
any herbal remedies or nutritional supplements with their care provider to ensure there are
not interactions with the ARV medication and the impact of the alternative therapies can be
monitored in terms of overall health, nutritional status, cost and well being.
Food-Drug Interactions
The interactions between HIV, medication and nutrition are complex. Nutrients and
substances in foods can interact with drugs—both anti-HIV medication and other meds—
26
Development of Nutritional Guideline for PLHIV
either enhancing or diminishing the effect of the medication. In addition, some foods can
change the absorption of drugs. This is why following food requirements for certain drugs is
so important. By not following recommendations, the level of the drug in your blood may
decrease to the point where it is like missing a dose. This can lead to viral resistance and the
need to change therapy. Generally, having some food when taking medications (provided
there are no fasting requirements) can reduce side effects and improve tolerance.
Balancing Food and Medication
PLHIV who are receiving ART or taking other OI medications need to be careful about what
foods they eat. The combination of medicine and certain foods can interfere with drug
metabolism. Before commencing ART it is recommended that a nutritional assessment be
completed on the individual (95). Be sure to know the food requirements for all your
medications. Following food guidelines is part of succeeding with your therapy. Unless
meds must be taken without food, try to eat something with each dose. This will make the
meds easier to tolerate, especially with the morning dose. For longer term side effects of
ART (e.g. raised blood fats: hyperlipidaemia) ensuring adequate food to eat to prevent or
treat malnutrition takes priority in resource poor settings.
Key Points



Nutrition interventions are an important complement to ART, not a replacement


Herbal remedies have a potential interaction with some ART
A nutrition assessment should be completed on all PLHIV commencing ART
Symptoms of ART can be common among PLHIV, nutrition interventions can help
manage these complications
PLHIV should be encouraged to disclose any herbal or nutrition supplements they
are taking with the HIV care provider
27
Development of Nutritional Guideline for PLHIV
Chapter Seven: PLHIV and Food Security
PLHIV and Food Security
Food security is ‘when all people at all times have both physical and economic access to
sufficient food to meet their dietary needs for a productive and healthy life’(96). The
definition is comprised of three components which include food availability, food access and
food utilisation. Food availability refers to food that is available from local production and
imports (including food donations). Food access refers to an individuals or households
ability to obtain adequate financial or other resources to be able obtain (by either buying or
bartering) food. This also can refer to the individual’s/ households physical ability to access
places where food is available for purchase. Food utilisation is a broad term that refers to
the ability of an individual or household to store and prepare that food in a way that the
body can safely digest and absorb nutrients contained within. This term can be extended to
include other dimensions of how the body utilises the nutrients from the food(96).
In Bangladesh, food insecurity is one of the biggest problems faced by PLHIV. At an
individual household level this often reduces the amount of income available for the
purchase of food. As the disease progresses, it can become even harder for a family to
cope, especially as resources are drained — for instance, valuable assets, such as livestock
and tools, may need to be sold in order to pay for food and medical expenses — and
poverty advances. Without food or income, some family members may migrate in search of
work, increasing their chances of contracting HIV — and bringing it back home. For others,
commercial sex may be their only option to feed and support their family. Food insecurity
also leads to malnutrition, which can aggravate and accelerate the progression of HIV(97).
Approaches to Food Security in HIV
Food and nutritional support are important components of comprehensive HIV care,
particularly in areas where malnutrition and food insecurity are common. Food and
nutritional support is not the same thing and whilst nutritional support is always included as
a comprehensive component of HIV care, food support may only be used in certain
contexts.
Food support (rations) for nutrition may be provided to HIV affected households to reduce
risk of OIs or side-effects of ARVs. Food support is generally provided for only a limited
period time until people are able to provide for their own food needs. It is sometimes used
as a buffer as part of other livelihood strategies. This may be in the form of food provided
through treatment centres, as part of Home based care, or provided to the general
population through other food support interventions
In HIV, food support is sometimes provided as a means of supporting the nutritional status
of PLHIV. Food support may be used to promote adherence during the early phase of
initiating ART. Food support is also provided as part of Home Based Care in the form of
individual foods (such as rice, beans, oil and salt). This is often provided as a family ration to
ensure that the person living with HIV gets a maximum benefit from the support. Other
28
Development of Nutritional Guideline for PLHIV
interventions may also include nutrition screening, basic medical care, counselling and
welfare support.
As the individual’s health improves and they become more independent it is important to
consider other livelihood strategies to help promote the long term health benefits of
improving nutritional status. Some of the strategies include:
 Microcredit programs
 Small grants
 Vocational training
 Home gardening
 Food cooperatives.
Strategies for Food Security of Households with PLHIV
In addressing issues relating to food security in HIV/AIDS a range of targeted strategies
should be considered. The following examples are derived from the FAO manual on
‘Incorporating HIV/AIDS Considerations into Food Security and Livelihood Projects’(98).
Individual Food Budgeting: Many PLHIV have problems having enough money to buy food.
It is important to teach the client or ideally the person who does most of the shopping and
cooking strategies to make their money go further. The following strategies may be helpful
for enhancing food security of the client.






Making a shopping list can reduce the number of ‘impulse purchases’, even something
as simple as shopping after the client has eaten can make a big difference to the amount
of money spent at the market.
Buying fruit and vegetables in season is usually a lot cheaper than buying the same items
at other times of the year.
If the client is cooking for themselves at home rather than buying food at a street stall,
cheaper meats may not necessarily be of poorer quality.
Shopping in-groups of neighbours, family and friends may also reduce the total price of
goods purchased as it is usually much cheaper to purchase items in bulk rather than
smaller quantities.
If an item can be stored for extended periods of time (either on the shelf and frozen) it
may be cheaper to buy foods in bulk.
Keeping a small supply of non-perishable foods is a good idea at times when a person is
hungry but is unable to leave the house. Certain items such as skim milk powder, tinned
fish, rice (if stored in an airtight container), beans and tinned products are able to be
stored for long periods of time.
Food Security Strategies -Awareness Raising: The link between HIV/AIDS, food insecurity
and malnutrition should be highlight among people involved in policy and program
formulation planning and project development in order to:
 Review and incorporate HIV /AIDS considerations into existing development policies,
programs and projects
29
Development of Nutritional Guideline for PLHIV

Incorporate food security considerations into policies programs and projects
Nutritional Care for People Living with HIV/AIDS: Consideration should be given to
including food security interventions in care and support programs. Examples of these
programs include:
 Home and community gardening programs and other agricultural interventions
 Development local food banks and external food aid
 Nutrition education and communication
 Programs and related training need to be developed and maintained.
Livelihood and Food Security Support: involves supporting the income generating potential
of HIV affected households by:
 Supporting food production and diversification.
 Introducing labour and time saving approaches.
 Promoting income generation and protecting productive assets such as machinery and
livestock.
 Consideration should be given to the household type when planning food security
programs.
30
Development of Nutritional Guideline for PLHIV
Strengthening Community Based Care and Support: many families affected by HIV/AIDS
become increasingly dependent on community services for care and support. These
services can be strengthened by providing enhanced food security programs and promoted
in communities where services do not exist. This includes strengthening the capacity of
services such as orphanages, schools and self-help groups to provide nutritional care, meal
services and/ or food assistance.
Key Points




Food security is ‘when all people at all times have both physical and economic access
to sufficient food to meet their dietary needs for a productive and healthy life’
Food insecurity is one of the biggest challenges for PLHIV in Bangladesh
Food insecurity also leads to malnutrition, which can aggravate and accelerate the
progression of HIV
All HIV care and treatment programs should assess and where possible integrate food
security interventions as a core part of their program
31
Development of Nutritional Guideline for PLHIV
Chapter Eight: Nutritional Interventions for PLHIV
Nutrition Interventions for PLHIV
It is important to develop a comprehensive plan when developing any sort of care and
support intervention to ensure that strategies are well targeted and appropriate to the
priority community. A good plan should, where possible, target a range of nutrition
strategies across the continuum of care to aid in achieving the project goals and contributing
to overall project sustainability. By using only one nutrition strategy, project implementers
address only one aspect of the care system, not only does this neglect potential nutrition
interventions at other levels of the health care system but also threatens to long term
sustainability of the nutrition activity.
The following section outlines a number of potential areas where nutrition interventions can
either directly or indirectly be implemented across the continuum of care. Examples of
nutrition interventions are included at various levels across the continuum of care as
outlined in Table 8.1.
Table 8.1 Examples of Direct Nutrition Interventions
Examples of Nutrition Interventions
National Level
Government
District and Specialist Hospitals
Universities and other Education Facilities




Inpatient Dietetic Interventions
Nutrition and HIV policy development
Care provider education and curriculum
development
Food support programs
Government
Community Hospitals
District Health Centres
Ambulatory Care Centres




Individual & group nutrition counselling
IEC Resource Development
Nutrition research (clinical and social)
HCW training
Community Level
Home-based Care
Non-Government Organisation
Community Based Organisation
PLHIV Self Help Groups




Individual & group nutrition counselling
Food Security Projects
Food Distribution Projects
Volunteer and PLWHA peer education
Regional Level
The terms food and nutritional support are not interchangeable, and while nutritional
support is always an element of HIV care, support, and treatment, food support may be
appropriate only in certain contexts. Nutrition interventions may or may not include the
provision of food, they may also include other types of interventions such as nutrition
assessment, education, counselling on specific eating behaviours, prescription of targeted
32
Development of Nutritional Guideline for PLHIV
nutrition supplements (e.g., micronutrient supplementation, therapeutic feeding), and
linkages with food-based interventions and livelihood programs. This paper focuses on the
integration of food support as part of a comprehensive model of care for PLHIV. Food
support is one example of nutrition intervention in HIV care and treatment. Figure 8.2
outlines the relationship between food support and other nutrition interventions.
Figure 8.2 Examples of Nutrition Interventions
‘Nutrition Interventions’
Nutritional
Assessment &
Dietary Counselling
Nutrition
Screening
Care Provider
Education Programs
Food Support
Supplementary
feeding
Therapeutic
feeding
Following are some examples of Nutrition Interventions commonly integrated into HIV
programs.
33
Development of Nutritional Guideline for PLHIV
Nutritional Assessment and Dietary Counselling for PLHIV
Figure 8.3 Examples of Nutrition Assessment Tools
a. Anthropometrical tools:
Weight: Measuring weight is the most commonly used anthropometric tool to diagnose
and follow up wasting in HIV infected individuals.
Body Mass index (BMI): It is an also simple and easy anthropometric tool to assess the
nutritional condition of adults. It is measured by the following formula
BMI= Weight in Kg/ (height in meter)2
BMI less than 18.5 in adults is defined as chronic energy deficit (CED).
Mid - Upper Arm Circumference (MUAC): It is also relatively easy to measure and it is
recommended for assessing acute adult under nutrition at population level.
There are also other anthropometrical methods to assess the nutritional status such as
waist circumference etc. There are also examples of assessment tools used in a clinical
context, these can be found in Annex 1.
Nutrition assessment and dietary counselling is a good example of how nutrition
interventions can be integrated into the care of PLHIV. Nutritional status can be measured
by anthropometric tools, clinical examination and also by biochemical tests. Figure 8.3
outlines common assessment tools used in nutrition assessment of PLHIV.
This type of assessment and counselling can take place in a variety of settings from a
hospital inpatient department or outpatient setting, community health centre or often in
the client’s home.
Individual nutrition counselling often incorporates:
 An assessment of dietary intake (meal patterns and consistency) and nutritional status
 Anthropometry and Body composition assessment (including height weight and LBM
assessment)
 Assessment of psychosocial and lifestyle factors affecting nutritional status
 Use of nutritional supplements and complementary therapies
 Drug-nutrient interactions
 Nutrition related Quality of life
 Developing strategies to address key issues identifies in the assessment.
During nutrition counseling help PLHIV or their caregivers to:
• Make informed choices for improving their nutrition.
• Identify and use locally available foods to meet their nutritional needs.
• Understand and adopt practices that promote a healthier nutritional status.
34
Development of Nutritional Guideline for PLHIV
• Understand how to use diet to manage common HIV related conditions.
Following issues are examples of topics discussed during Nutrition Counselling:
 General counseling on nutrition and HIV.
 Specific counselling on eating well.
 Counselling on how to avoid infections.
 Counselling for PLHIV on the importance of physical activity.
 Counselling for PLHIV with HIV related symptoms
Other Examples of Nutrition Interventions
Other types of nutrition interventions include:
Nutrition Screening: identifies PLHIV most vulnerable to malnutrition and refers them for
further nutrition assessment and intervention. Screening tools are often short and easy to
implement and can be integrated into standard practice.
Care Provider Education Programs: these nutrition training programs aim to build the skills
of all care providers to provide nutrition interventions for PLHIV. They include components
of basic nutrition, relationship between HIV and nutrition and nutritional management of
PLHIV. The target groups of these interventions can be quite diverse including medical
officers, nurses, counsellors and peer educations.
Food Support Interventions
There are a large variety of food support interventions that may be incorporated as part of
HIV prevention and care. These interventions can have a value role in HIV prevention
particularly when food is used as incentive to promote more secure livelihoods. In terms of
HIV care, food support can play an important role in improving nutritional status, enhancing
tolerance to treatments or as an incentive to continue with treatment. Following is a
summary of these types of interventions.





Program Based Feeding: Food is provided in the form of a regular meal for recipients
attending a health or support service. Recipients may also receive nutrition education
and skills building such as food preparation and hygiene.
Food for Training/ Education (FFT/FFE): Food support is linked to home based workers,
Income generating activities (IGA) and micro-credit programs.
Food Rations: Food support is provided to specific groups who may be particularly
vulnerable to malnutrition (such as pregnant women or OVC). Sometimes rations are
also used as an incentive to encourage patients to return for follow-up care e.g. PMTCT.
Home Based Care: Food support usually in the form of individual foods (such as rice, oil,
salt) is provided to people requiring home-based care. Interventions may also include
nutrition screening, basic medical care, counselling and welfare support. Often these
programs progress the client to other forms of support such as vocational training,
income generating and livelihood programs.
Therapeutic Feeding Programs: involves the provision of specialised foods to treat
people experiencing moderate to severe malnutrition. Therapeutic feeding often
35
Development of Nutritional Guideline for PLHIV
involves the use of Ready-to-Use Therapeutic Foods (RUTF) which are commercially
designed to meet the nutritional requirements to reverse malnutrition.
Key Points
 Nutrition interventions should be planned at community regional and national levels.
 Nutrition interventions include a wide range of potential activities, one of which


includes provision of food support
Nutrition assessment and counselling is a primary example of a nutrition
intervention
Integrating nutrition interventions into HIV care and treatment programs is an
important component of comprehensive HIV care.
36
Development of Nutritional Guideline for PLHIV
Chapter Nine: Monitoring and Evaluation of Nutritional Care Activities
Aspects of Monitoring and Evaluation in Nutrition Programs
It is important to monitor and evaluate the implementation of the nutrition interventions
and review them in the light of local experience. Given the diversity of nutrition
interventions available, there are also a number of ways this can be achieved. It is
important to identify particular processes in implementing these types of assessments and
how these can be integrated into existing programs. Each of these are critical elements to
the design and implementation of any nutrition intervention as part of an HIV program.
Types of Monitoring and Evaluation:
Needs Analysis or Assessments: this stage involves establishing a solid understanding of the
current situation of the target group and the factors that contribute to this. In terms of
nutrition and HIV this involves gaining an understanding of the nutrition situation of PLHIV
and identifying the factors that contribute or reinforce that situation. Information gathered
during this phase of intervention is then often used as a baseline to determine the
evaluation indicators of the program. Examples of tools or strategies that are often used
during this phase include literature reviews, focus group discussions, client-centered
interviews, questionnaires and surveys, and stakeholder meetings.
Formative Evaluation and Piloting: this type of evaluation is often included in the early
phases of program implementation. It is designed to identify any potential problems with a
program or project before significant levels of resources are invested in implementing the
activity. Examples of this may include conducting a small pilot of a resource or training
program among a group of key stakeholders before the project is printed or delivered on a
large scale. This process helps identify potential problems or unforeseen issues with an
activity that can usually be corrected before larger scale rollout.
Project Monitoring: this involves collecting and reviewing information about the inputs (the
resources invested), processes (how the resources are utilized) and outputs (what is
produced and how quantity) of the project. Using a nutrition example this may involve
collecting information about the number of clients receiving nutrition assessments over a
given time period, or the number of care providers receiving nutritional training. This
information contributes to the overall objective of the project.
Project Evaluation: this measures the overall outcome and impact of the program, or how
the project has met its aim or goals. It is usually conducted on a less frequent basis than
monitoring and it measures outcomes such as changes in knowledge and practice, or
changes in some form of behaviour or health status.
Tools for Monitoring and Evaluation
Whereas a method refers to the approach to a monitoring, evaluation, or research activity, a
data collection tool refers to the instrument used to record the information that will be
gathered through a particular method. Tools are central to quantitative data collection
37
Development of Nutritional Guideline for PLHIV
because quantitative methods rely on structured, standardized instruments like
questionnaires. Tools (such as open-ended questionnaires or checklists) are often also used
in qualitative data collection as a way to guide a relatively standardized implementation of a
qualitative method. Tools may be used or administered by program staff or may be selfadministered (meaning that the program participant or client fills in the answers on the
tool). If tools are to be self administered, there should be procedures in place to collect the
data from clients who are illiterate. Space, privacy, and confidentiality should be observed.
Some common quantitative M&E tools include:
• Sign-in (registration) logs
• Registration (enrollment, intake) forms; checklists
• Program activity forms
• Logs and tally sheets
• Patient charts
• Structured questionnaires
Examples of qualitative M&E tools include:
• Focus group discussion guide
• Direct observation checklist
• In-depth interview guide
Following are some examples of how monitoring and evaluation concepts can be integrated
into nutrition interventions.
Specific examples of this could involve:
 Monitoring the number of people trained and the number of copies of guidelines and
training programs distributed;
 Follow-up meetings with key persons in agencies involved in the development of the
local guidelines to assess the experience within their agency of the use of the manual;
 Monitoring number of clients receiving nutrition assessments and dietary counselling
 Measuring changes in knowledge, attitude or practice of those involved in HIV care.
 Number of PLHIV receiving food support
 Evaluating the impact of nutrition interventions in terms of the factors that contribute to
PLHIV nutritional status, and nutritional status itself.
Key Points
 Monitoring and evaluation is an important component of all nutrition activities
integrated as [part of HIV care
 As there are a diverse range of nutrition interventions the tools and outcomes
measured are also different
 The key elements of needs analysis, formative evaluation, monitoring and evaluation
are important to all nutrition interventions.
38
Development of Nutritional Guideline for PLHIV
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in resource-limited settings. Consultation on Nutrition and HIV/AIDS in Africa: Evidence,
lessons and recommendations for action; 2005 10-13 April 2005; Durban, South Africa.
World Health Organisation.
96.
USAID. Policy Determination: Definition of Food Insecurity. In: USAID, editor.: USAID;
1992. p. 3.
97.
Weiser SD, Leiter K, Bangsberg DR, Butler LM, Percy-de Korte F, Hlanze Z, et al. Food
insufficiency is associated with high-risk sexual behavior among women in Botswana and
Swaziland. PLoS Med. 2007 Oct 23;4(10):1589-97; discussion 98.
98.
FAO. Incorporating HIV/AIDS Considerations into Food Security and Livelihood
Projects. Rome: FAO; 2003.
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Development of Nutritional Guideline for PLHIV
Annex 1: Clinical Nutritional Assessment Tools
Clinical Nutrition Assessment
The initial visit of a new HIV-positive patient should include clinical screening for nutritional
risk. A validated screening tool is needed to assess the degree of nutritional risk. The
purpose of screening is to categorize a patient’s nutritional needs as low, moderate, or high
risk for nutritional compromise. Follow-up visits of stable HIV-positive patients should
include an annual screening for nutritional risk.
I. High risk
A.
B.
C.
D.
F.
G.
H.
I.
J.
15% unintentional weight loss within 4 weeks or in conjunction with
1. Chronic oral [or esophageal] thrush.
2. Dental problems.
3. Dysphagia.
4. Chronic nausea or vomiting.
5. Chronic diarrhea.
6. CNS disease.
7. Intercurrent illness or active opportunistic
infection.
10% unintentional weight loss over 4–6 months
Poorly controlled diabetes mellitus.
Pregnancy (mother’s nutrition; infant: artificial infant formula).
Severe dysphagia.
Enteral or parenteral feedings.
Two or more medical comorbidities, or dialysis.
Complicated food-drug-nutrient interactions.
Severely dysfunctional psychosocial situation
II. Moderate risk
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
Oral thrush.
Chronic nausea or vomiting.
Chronic diarrhea.
Dental problems.
Chronic pain other than oral/gastrointestinal tract
Osteoporosis.
Hypertension.
Evidence for hypervitaminoses or excessive supplement intake.
Inappropriate use of diet pills, laxatives, or other over-the-counter medications.
Substance abuse in the recovery phase.
Possible food-drug-nutrient interactions.
Obesity.
Evidence for body fat redistribution.
Elevated cholesterol (1200 mg/dL) or triglycerides (1250 mg/dL), or cholesterol
!100mg/dL.
45
Development of Nutritional Guideline for PLHIV
O.
P.
Q.
R.
S.
T.
U.
Diabetes mellitus, controlled or new diagnosis
Food allergies and intolerance.
Single medical comorbidity.
CNS disease resulting in a decrease in functional capacity.
Eating disorder.
Evidence for sedentary lifestyle or excessive exercise regimen.
Unstable psychosocial situation
III. Low risk
A.
B.
C.
D.
E.
F.
G.
H.
Stable weight.
Appropriate weight gain, growth, for adoloscent
Adequate and balanced diet.
Normal levels of cholesterol, triglycerides, albumin, and glucose.
Stable HIV disease (with no active intercurrent infections).
Regular exercise regimen.
Normal hepatic and renal function.
Psychosocial issues stable
(Adapted from nutritional screnning form American Dietetic Association and the Los Angeles
County Commission on HIV Health Services)
During nutrition assessment, family and medical history should be considered, particularly
regarding diabetes, coronary artery disease, hypertension, and other cardiac risk factors.
Recommendations (individualized care plans) should be adapted to stage of HIV
progression, from asymptomatic to advanced stages with active secondary infections.
Socioeconomic, cultural, and ethnic background should be considered, including a history of
mental health disorders or substance abuse as well as literacy level and financial status.
c. Biochemical assessment: This is useful mainly for detection of specific nutritional
deficiencies for example, heamoglobin levels, total ferrtin level etc for anaemia, serum total
protein, Serum total albumin, specific micronutrients levels etc.
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Development of Nutritional Guideline for PLHIV
Annex 2: Clinical Nutritional Education Tools
Patient Information Sheet: Food Safety and Hygiene
Food hygiene is particularly important for people living with HIV. Relatively minor food
and water borne illnesses can become serious infections. Many of these infections can be
prevented by paying attention to personal hygiene and sanitation. Food preparation and
consumption also have an important role to play. These suggestions will help reduce the
risk of food borne illness.
Meat: When buying meat from market, make sure that the meat has not exposed to too
much sun, dust or air, particularly cooked meat. These meats may be contaminated with
bacteria, which can cause food poisoning. Meat should have a fresh smell.
Fruits & Vegetables: Check for freshness and any insects or fungus.
Milk & Milk Products: Packages or containers must be in good condition, make sure the
seal is intact. Check the expired date to ensure the product is in good condition e.g. fresh
milk must not go sour or have a strong smell. Milk powder should be stored in an airtight
container with no moisture.
Dry food: e.g.. Rice, dry chilli, garlic, beans, pulses etc. should be free from insects and
fungus.
Guidelines for Preparing Food











The preparation area, utensils and wash hands before preparing food for PLHIV should
be clean.
Wash hands with soap and water prior to touching food and after using the toilet.
Place food on clean plates or containers and cover with a clean covering after
preparation to prevent dust, germs and flies from contaminating the food.
Separate pets from food preparation or dining areas.
After chopping raw meats and seafood ensure that the utensils and chopping board are
washed well in hot soapy water before preparing any other foods. Alternatively use a
separate chopping board for raw meats, raw vegetables and cooked foods.
Keep uncooked foods and cooked foods separate.
Any leftovers from a previous meal should be refrigerated immediately and then only
reheated once.
If there is any doubt about the quality of the food throw it away rather than risking
food poisoning.
Eat clean and freshly cooked food. Make sure that food which has previously been
prepared (e.g.. Food bought from markets or been refrigerated) has been well heated
(all the way trough) before eating.
Foods that are meant to be kept cold should be stored in the refrigerator or at least in
a cool place if a refrigerator is not available.
Before you prepare any fruit or vegetable make sure it is well washed in clean water.
Strategies for Preparing Clean Water

To prepare water for washing food, fill a saucepan with water and bring to a rolling boil
for ten minutes. Let this water cool and store in a clean bottle.
For more nutritional advice ask your health care provider or a dietitian/nutritionist
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Development of Nutritional Guideline for PLHIV
Promote Good Personal Hygiene:



Always wash hands with clean water and soap or ashes before, during and after
preparing food or eating, and after visiting the toilet. Dry hands on a clean cloth or
towel.
Cover all cuts and wounds to prevent contamination of food during preparation and
handling.
Use safe clean water from protected sources such as treated piped water supplies,
boreholes, gravity feed schemes and protected wells. If the water is not from a
protected source, it should be boiled before consumption. Care must be taken during
collection and storage to use clean containers to prevent contamination. Water
containers in the home can easily become contaminated by dirty cups and hands
that have not been washed. When people drink contaminated water they will become
sick.
Hygiene in the Food Preparation Area




Keep all food preparation surfaces clean. Use clean dishes and utensils to store,
prepare, serve and eat food.
Wash vegetables and fruit with clean water.
Cover food to prevent both flies and dust from contaminating the food.
Keep rubbish in a covered bin (and empty it regularly) so it will not cause offensive
smells and attract flies, which can contaminate food with germs.
Cooking and Storage of Food
Germs multiply more quickly in warm food. Storing food in a refrigerator or cool place
slows down this growth. Cooking on a high heat can also kill most germs. Food should
be:






Served immediately after cooking. To avoid germs multiplying, food should not be
left standing at room temperature before eating, to avoid germs multiplying.
Covered and stored in containers away from insects, rodents and other animals.
Stored in a cool place or refrigerator where available especially fresh meats, chicken,
fish and dairy foods.
Cooked thoroughly, but do not overcook vegetables.
Stored in separate containers for raw and cooked food together. Containers will
avoid contact between them (cross contamination)
Discarded after cooking if there is leftovers unless they can be kept in a refrigerator
or a cool place. Do not store them for more than one or two days and always reheat
them at a high temperature.
Animal foods




Cook meat and fish well; meat should have no red juices.
Wash utensils and surfaces touched by animal products with hot water and soap
before preparing other foods.
Keep meat and fish separate from other foods.
Eggs should be hard boiled. Do not eat soft-boiled eggs, raw eggs, cracked eggs or
any foods containing raw eggs.
However careful one is, food-borne infections may happen. The advice for diarrhoea will
help, but when a person has serious food poisoning it is important to see a health
worker without delay in order to avoid weight loss and further illness.
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Development of Nutritional Guideline for PLHIV
INFORMATION SHEET - GAINING WEIGHT
If you are underweight or you are losing weight unintentionally it is important to increase your
weight.
Why have I lost weight?
When a person does not eat enough food, or the food eaten is poorly absorbed, the body draws
on its reserve stores of energy from body fat and protein from muscle. As a result, the person
loses weight because body weight and muscles are lost. Infections can increase a person’s need
for food so even if you have not changed the amount you eat you may lose weight.
How to gain weight
Weight is gained by eating more food, either by eating larger portions and/or eating meals
more frequently. Here are some suggestions for gaining weight:
Try to eat three good meals daily with frequent snacks in between.
Energy and Protein Foods
 Eat more staple foods such as rice, noodles, potatoes, bread and bananas.
 Increase intake of beans, soy products, lentils, peas, groundnuts and seeds.
 Include all forms of meat, poultry, fish and eggs as often as possible. Minced meat, chicken
and are easier to digest. Offal (such as kidney and liver) can be the least expensive source.
 Eat two types of protein foods together in dishes e.g. chicken and egg, pulses and chicken,
beef and beans
 Introduce more dairy products such as full-cream milk, sour milk, buttermilk, yoghurt and
paneer into your diet.
 Add dry milk powder to foods and drinks such as milo, yoghurt, mashed potato or sweet
potato or soups. Some people may find milk difficult to digest. It should be avoided if it
causes cramps or skin rashes.
 Add sugar, honey, jam, syrup and other sweet products to foods.
Fats
 Slowly increase the fat content of the food by using more fats and oils and fatty meat. If
problems with a high fat intake are experienced (especially diarrhoea), reduce the fat intake
until the symptoms are over and then gradually increase it to a level that the body can
tolerate.
Snacks
Eat snacks regularly between meals. A snack is any nutritious food that is readily available and
can be eaten without much preparation.
Sick Days
 If a person needs to stay in bed, keep food and water within easy reach.
Recipes
Try some recipes following these recommendations for gaining weight.
For more nutritional advice ask your health care provider or a dietitian/nutritionist
49
Development of Nutritional Guideline for PLHIV
PATIENT INFORMATION SHEET - FOODS TO EAT WHEN YOU HAVE DIARRHOEA
Diarrhoea describes the symptoms of an upset stomach that results in 3 or more, loose or
water bowel motions per day. It can be accompanied by cramping and vomiting.
Try these suggestions to help improve your symptoms:






Eat small amounts regularly throughout the day.
Try herbal teas and soups instead of alcohol and caffeine containing drinks such as tea
and coffee as they may make your diarrhoea and dehydration worse.
Reduce or avoid large amounts of cow’s milk or goat’s milk as they can make severe
diarrhoea worse.
If your diarrhoea is only mild (less than 4 – 5 motions a day) small amounts of yoghurt
and fermented milk may improve your symptoms.
Very spicy foods such as chillies and pepper may sometimes make diarrhoea worse.
When you have diarrhoea, fat may not be easily absorbed. Try to reduce your intake of
fat in cooking and in food preparation. For example, avoid fried food, fatty meats, crispy
fish, coconut cream and fried chicken.
Fluids
Severe diarrhoea that last for more than a couple of days can lead to dehydration which can
be life threatening. It is important to drink plenty of liquids to replace lost fluid and to
provide some energy. For example rice water with a little salt, clear broth, water that has
had cook noodles, green coconut water, weak or diluted cordial or fruit juice.
Try one of the following Oral Rehydration Solutions (ORS):
From ORS Packet
Follow the instructions and dissolve the contents of the packet in the amount of clean water
that is stated on the packet.
With sugar and salt
To one litre of clean water, add half a teaspoon of salt and eight teaspoons of sugar. Stir or
shake well. The water should taste no more salty than tears.
Or, with powdered cereals
To one litre of clean water, add half a teaspoon of salt and eight teaspoons of powdered
cereals. Rice is best, but fine ground wheat flour, maize, sorghum or cooked mashed
potatoes can also be used. Boil for 5-7 minutes to make a liquid soup or watery porridge.
Cool and drink quickly.
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Development of Nutritional Guideline for PLHIV
FOODS TO EAT WHEN YOU HAVE DIARRHOEA (Continued)
Minerals
Diarrhoea may result in a loss of many minerals from the body, especially potassium.
Potassium is a salt found in foods like bananas, cooked mushrooms, tomatoes, oranges and
dilute fruit juices. Try to include some of these foods in your diet daily. Remember that fruit
juices should be diluted by half by mixing with boiled water.
Fibre
Eat refined foods (soluble fibres) such as white rice, maize meals, white bread, noodles and
potatoes.
Foods with harsh types of fibre may also make your diarrhoea worse. Try to reduce the
amount of harsh or insoluble fibre from your diet by:
Removing all skin, pips and seeds from fruit and vegetables before eating or cooking such as
tomato skin and pips
Foods made from dried beans, peas and legumes may make diarrhoea worse. These also
include soybeans, mung beans, and red beans.
Avoid dried fruit, watermelon seeds, sunflower seeds.
Recovery
When the symptoms of diarrhoea have improved, you should be able to return to a normal,
well balanced diet over a week by slowly reintroducing foods like unpolished rice, noodles, and
then as the next step fruits and vegetables.
If the diarrhoea persists for more than three days, fever develops, blood appears in the stool
or you become very weak, seek advice from a health worker.
For more nutritional advice ask your health care provider or a dietitian/nutritionist
51
Development of Nutritional Guideline for PLHIV
INFORMATION SHEET - IMPROVING A POOR APPETITE
Poor appetite is a very common problem. This is when the feeling of hunger
disappears or you are easily full. When this happens you may not eat enough to stay
well.
Poor appetite can have many causes including infections which may also cause
diarrhoea, nausea, mouth pain and taste changes. Tiredness and depression may
make you lose your hunger. Your appetite can also be reduced when you have not
eaten enough food to provide all the vitamins and minerals your body needs.
Even though you do not feel hungry it is very important to continue eating to prevent
weight loss, malnutrition and to maintain strength in order to improve your health.
If the reason for your lack of appetite is diarrhoea, nausea and vomiting, or a sore
mouth, also follow the guidelines given on the information sheets for these conditions.
Ask your health care worker for these sheets if you do not have them.
When you are not hungry the best way to regain appetite is to eat
Meals
 Eat smaller meals more often. Try to eat at least every 2 to 3 hours. Eat whenever
your appetite is good - do not be too rigid about fixed times for meals.
 Try different foods until you find those that you like.
 Choose high calorie foods and snacks e.g. dried fruits, nuts, eggs, tofu, chicken
 Add oil to noodles and vegetables to provide more energy.
 Add flavour to food to make it look and taste interesting. Squeeze some lemon
juice over it or add spices such as cardamom, fennel, coriander and cinnamon.
 Choose a variety of foods to make eating interesting.
Drinks and Fluids
 Try to drink a lot of nutritious fluids throughout the day for e.g. milk, yoghurt,
sour milk, soups, teas with honey or juices.
 Try a meal in a cup if eating solid foods is difficult. Try blended fruits with yoghurt
or blended soups.
 When eating drink mainly after, and in between meals - do not drink too much
before or during meals.
 Avoid fizzy drinks, beer and foods such as cabbage that create gas in the stomach
and can make you feel bloated.
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Development of Nutritional Guideline for PLHIV
IMPROVING A POOR APPETITE (Cont)
Food Preparation
 If possible avoid food preparation areas. The smell of food can sometimes make
you feel full or sick.
 Prepare cold foods if the smell of cooking makes you feel sick.
 Choose an attractive large plate for serving small amounts of food to make the
meal look more appetising
 Eat in a well-ventilated room away from unpleasant smells.
 Try rinsing your mouth out before eating as this can make food taste fresher.
 At the table, make the surroundings appealing, try flowers on the table or
colourful fruit or vegetables displayed.
 Play some soft music at meal times
 Take light exercise such as walking outdoors, for example, and breathing plenty of
fresh air to stimulate an appetite before meals
Eat with your family or friends. If you have to stay in bed, they can join you at your
bedside.
If you get hungry but feel full very quickly….




Eat foods that will give you the most nutrition in smaller amounts for e.g. eggs,
chicken, lamb, beef with rice, potato or noodles
Do not drink too much fluids before or during meals
Eat when you are hungry even at odd times, for example eating rice at 2 in the
morning
Try some of the suggestions above
For more nutritional advice ask your health care provider or a nutritionist.
Information in these sheets are derived from a number of sources including the FAO
‘Living Well with HIV/AIDS’ Handbook
53
Development of Nutritional Guideline for PLHIV
INFORMATION SHEET – FOOD THAT ARE EASIER TO CHEW AND SWALLOW
It can be very difficult to maintain a 'normal' intake of food when you find it hard or painful
to chew or swallow. These problems can be caused by ulcers or pain in the mouth, a sore
throat, or a dry mouth. If any of these affect your ability to chew or swallow food these
suggestions may help.











Choose food that is soft or fine like egg, steamed fish, thick soup, noodles in broth,
blended fruits, soft desserts, custard, banana puddings and ice cream.
Try to chop meat and vegetables, noodles and fruit finely before adding to dishes to
reduce time taken to chew food, or blend some ingredients.
If you have problems swallowing, clear soups may be hard to eat - try adding oily flour,
corn flour to make them thicker or add Agar Agar powder to make it jellied which will be
easier to swallow.
If you eat noodle broth or noodle soup, cut up noodles in one or two inch lengths so
that they aren't in long strands. This will make the food easier to eat and less time
chewing.
Avoid crunchy, chewy or hard foods, crispy naan, crunchy desserts or crispy fried foods
such as rice cakes, nuts, cookies or toast.
Add liquids to foods or soften dry food by dipping in liquids.
Very hot food may irritate sores in your mouth.
Some sour or salty foods may cause pain or sting your mouth or lips: examples might
include pineapple, oranges, lemon, chillies or food with too much vinegar, salt or fish
sauce.
Use a straw to drink liquid foods or water to avoid irritating any sores in your mouth.
Some foods like boiled rice may stick in your throat; rice gruel, rice porridge, rice
noodles, wonton and some wide noodles may be easier to swallow.
Sucking plain or flavoured ice blocks made from sweet drinks may numb your mouth
and reduce pain, making it easier to eat.
If you have problems eating you may try drinks with high energy or high in protein ask
your nutritionist to advise you on how to make these drinks or ask for advice on food
supplements.
Here are 3 Easy Examples:


If you drink cow’s milk, add 6 tablespoons of powdered skim milk per litre of milk and
use in the same way you would use cow's milk e.g.. milo, ovaltine, breakfast cereal.
Drink cow’s milk or soy milk blended with powdered milk, fruit, ice cream, flavours and
syrup, yoghurt, coconut milk etc.
To prevent sores in the mouth, brush your teeth at least twice a day and visit the Dentist
regularly.
If your gums are painful and brushing the teeth is not possible, rinsing the mouth with
bicarbonate of soda mixed with water will make the mouth feel fresh.
Information in these sheets are derived from a number of sources including the FAO ‘Living
Well with HIV/AIDS’ Handbook
54
Development of Nutritional Guideline for PLHIV
INFORMATION SHEET - NAUSEA AND VOMITING
Before the Individual Eats
 Encourage the person to rinse their mouth with cold water.
 Make the physical environment pleasant and airy.
 If possible avoid being in the kitchen when food is being prepared.
 Avoiding odours that make the individual feel nauseous.
What the Individual Should Eat
 Regular fluids: vomiting over a period of time can lead to problems such as
dehydration. Cordial, and rehydration formulas can help to alleviate this problem.
 Small frequent meals.
 Eating at times when client does feel hungry.
 Ginger foods may help.
 Other solutions to a poor appetite may include eating some salty crackers when
the client first wakes in the morning, this can sometimes reduce the amount of
nausea. Other anecdotal strategies include having a banana 30 minutes before a
meal, rinsing the mouth with cold water and sipping some ginger infused water.
 Cold foods may be better tolerated than hot foods.
After the Individual Finishes Eating
 Rest after a meal but avoid lying flat. Encourage the person to use pillows to keep
the head and shoulders slightly raised if they do need to lie down.
55