Nutrition, the neglected side of AIDS care in developing countries

A Monday evening satellite session at the International Conference on AIDS, organised by Satellife and the Academy for Educational Development, USA, in Barcelona was packed into a tiny room which couldn’t seat everyone who turned up. This was symbolic, some thought, of the marginal status of what in fact is a crucial part of support for people with HIV and AIDS.

Pioneers in the field of studying nutritional deficits in HIV and AIDS, in defining AIDS wasting syndrome and pinning down why it is that people with AIDS so often have problems maintaining their weight, filled four hours with a series of presentations that offered many unresolved questions. There were presentations, too, on micronutrients which included evidence that nutritional deficiencies do strongly relate to risk of death – yet there are some risks from supplementation too, especially when nutritional deficiencies are not in fact present. There is a lot that remains to be found out, both about what is needed and what is safe.

As one of the session chairs, Ms Robin Jackson from the United Nations’ World Food Programme, observed, that organisation is now facing an unprecedented situation. 13 million people in Southern Africa are at risk of starvation, and WFP has to decide what food should be procured to deliver to them. Millions of those people happen to be living with HIV or AIDS and this surely should be taken into account when deciding on the issue. Yet no-one is really certain how it should be taken into account.

Dr Jean Humphrey reported from Zimbabwe on a major study of anaemia in pregnant women with HIV. Anaemia is the common lot of most African women, especially those who are pregnant. Much of this anaemia is due to lack of iron in the diet. It has emerged from a follow-up study of 7936 women, 38% of whom were HIV positive, tested for anaemia in antenatal clinics that there is a strong association between the level of anaemia and the risk of death for HIV positive women (Zvandasara). How should this be treated?

Dr Derek Macallan from St George’s hospital, London, reviewed the interaction of HIV, tuberculosis and nutrition. Tuberculosis is a wasting disease in itself, and it clearly makes a major contribution to the wasting experienced by many people with HIV in Africa. But is the cause of wasting in tuberculosis the same as that in HIV? And what can be done to correct either of them? Is it a cause for concern, that most of the weight gain that people achieve through medical means is in the form of fat rather than lean tissue, or is this a short-term imbalance that the body can correct when restored health is maintained for months and years? Interestingly, there is evidence that better nutrition can speed the rate at which people with TB on antibiotic treatment clear the bacteria from their lungs (and so become uninfectious).

Dr Nigel Rollins from the King Edward Hospital in Durban, South Africa, reported on the management of children with persistent diarrhoea. When HIV positive children suffer from chronic diarrhoea, do they need more and different treatment to other children with diarrhoea, and how should this be reflected in management programmes for the health of families in countries with limited resources? The erosion of their gut surfaces meant that they often had severe carbohydrate intolerance; indeed, detecting glucose in their stools was highly predictive of children’s HIV status. Children were slow to recover and so they were exploring the impact of continuing nutritional support after discharge from hospital, in a study with the Africa Centre funded by the Paediatric AIDS Foundation.

Mark Boyd, an Australian doctor who has been working in Thailand at the HIV-NAT centre in Bangkok, exploded the myth that Asians don’t suffer from lipodystrophy. In fact, although the syndrome still lacks a clear working definition, it was plain to see in the faces and bodies of all too many of the Thai patients he had been seeing. Even worse, there was a rate of diabetes and pre-diabetic conditions approaching 10 per cent in one long-term cohort. This precisely matches European experience as reported from France, and could not go untreated. The cost of treating diabetes (with drugs, not insulin) was low; the cost of treating raised lipids is now comparable to the cost of the cheapest ARV regimen available in Thailand. This is an issue on which we can expect to hear a great deal more at the next International AIDS Conference in Bangkok, July 2004.