1. Session 3: Nutrition and HIV Medications
Nutrition Management with HIV and AIDS: Practical Tools for Health Workers
Session 3 should take approximately 2 hours, 25 minutes
Step 1: Introduction and Learning Objectives (Slide 2) – 10 minutes
Step 2: Nutrition and ART (Slides 3-11) – 25 minutes
Step 3: Common Side Effects with HAART (Slides 12-17) – 10 minutes
Step 4: Counselling Before and During HAART (Slides 18-20) – 10 minutes
Step 5: Food and Medication Table Activity (Slides 21-23) – 45 minutes
Step 6: Case Studies (Slide 24) – 40 minutes
Step 7: Key Points (Slide 25) – 5 minutes
Step 1: Introduction and Learning Objectives (Slides 1-2) – 10 minutes
Begin this session by asking participants why they think nutrition is important with medications.
This should lead into a short discussion on the impact of food and nutrition status on medication tolerance, absorption, metabolism, and adherence.

2. Objectives Explain the importance of nutrition and HAART
Identify food effect or potential side effect for each antiretroviral medication
Counsel clients on food effects of medications by using the food-medication timetable
This session will cover important points about nutrition considerations with ART and other medications that clients take.
Review the objectives listed on the Slide with participants and ask if there are any questions.

3. Why is Nutrition Important with Medications?
Improved treatment effectiveness and efficiency
Prevention of side effects
Better adherence, means less resistance
Improved quality of life
Step 2: Nutrition and ART (Slides 3-11) – 25 minutes
Use this Slide to follow-up the discussion at the beginning of the session when participants were asked why they feel nutrition is important with medications.
Nutrition and food can improve the treatment effectiveness and efficiency.
Effective vs. Efficient. Define each – ask class to define. Discuss until entire class understands each concept. Effectiveness is how well the medication is taken into the blood system – from swallowing it to absorption into the blood. Efficiency is how well the medications are then used in the body and how they interact with other medications or food. Both are important as nutrition can affect each.
Food can help prevent side effects because a person who normally eats well and has a good weight may tolerate medications better than someone who is malnourished.
Similarly, a person who is malnourished or doesn’t have enough food may not take their medications by the regimen, leading to poor adherence and potential resistance.
Overall, being well nourished can improve the quality of life and survival for a person on ART.

4. Effects of Malnutrition and HIV on the Immune System
CD4 T-lymphocyte number
CD8 T-lymphocyte number
Skin sensitivity to infections
CD4 / CD8 ratio
Serologic response after immunizations
Bacteria killing
NB: this Slide is animated so that the arrows each come in each time you press the enter key (or space bar)
This list represents factors that determine how well our immune system functions. We generally look at lab values: CD4 and CD8. We also can tell immune function by skin sensitivity to infections, serologic response after immunizations and how well our bodies can kill or fight bacteria that invades the body.
The downward red arrows represent what happens to the immune system when a person has either or both malnutrition and HIV. Both weaken the immune system individually, but together the body has an even harder time fighting off infections and staying healthy.
Nutrition is important for both these situations. We know that good nutrition (balanced meals, adequate calorie, protein and micronutrient intake) can make a person well-nourished, consequently improving the immune system. This is true for someone who is malnourished and/or someone with HIV.
For people with HIV, ART can also improve the immune system, but this must be in combination with good nutrition.
Good
Nutrition
HAART

5. ARV vs. HAART
ARV: antiretroviral medication refers to the individual medications that are used to inhibit the multiplication of retroviruses like HIV
HAART: highly active antiretroviral therapy refers to the treatment regimens recommended by leading HIV experts to aggressively suppress viral replication and progress of HIV disease
ARV: antiretroviral medication refers to the individual medications that are used to kill or inhibit the multiplication of retroviruses like HIV
HAART: highly active antiretroviral therapy refers to the treatment regimens recommended by leading HIV experts to aggressively suppress viral replication and progress of HIV disease
We are distinguishing these two because ARV refers to just one HIV medication, for example when a pregnant woman receives single dose NVP for PMTCT. HAART refers to the triple combination therapy that a PLWHA will take for life.

6. Modern (New) Therapies
HAART: combination of 3 or more of the following:
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Nucleoside reverse transcriptase inhibitors (NRTIs)
Protease Inhibitors (PIs)
Therapies to treat opportunistic infections
Ex: TB treatment, antifungal, antibiotics
Malaria treatment
Multivitamin/mineral supplements
FACILITATOR: Refer participants to Handout 3.1 and review all food effects of each antiretroviral
When we talk about medications, we first look at modern or new therapies. Since HIV is a relatively new disease, these medications are also new with many side effects, interactions, and complications that we may not even know about yet.
People with HIV, once eligible based on their HIV stage, take highly active antiretroviral therapy (HAART), which consists of combination therapy using three classes of medications:
Non-nucleoside reverse transcriptase inhibitors (NNRTIs): Efavirenz and Nevirapine
Nucleoside reverse transcriptase inhibitors (NRTIs): Abacavir, Didanosine, Lamivudine, Stavudine, Zalcitabine, and Zidovudine
Protease Inhibitors: Amprenavir, Indinavir, Nelfinavir, Ritonavir, and Saquinavir
People with HIV often take other medications to treat opportunistic infections or other illnesses. These can be for tuberculosis treatment (a very common co-infection with HIV), antifungal, antibiotics, or antimalarial medications.
Modern or new therapies can also include dietary or nutrition supplements such as multivitamin/mineral supplements, which are often prescribed for clients on ART.

7. Traditional Therapies
Herbal remedies, teas/infusion, or high-dose vitamin supplements
Caution: some may interact with other medicines or foods
Ex: Avoid garlic supplements with Saquinavir
Some therapies may be expensive, replace food, and can cause liver damage (especially if combined with other medications)
Always ask clients what traditional therapies they are taking
Herbal therapies should be used with caution when talking about HIV. This is because, as said in the previous Slide, HIV is a new disease and the medications have not been used for very long. Therefore we’re still conducting research to tell us what the medications may interact with. But until now, we don’t know for sure which traditional medications ART or other medications may interact with.
Interactions can sometimes be dangerous because the ART may not work as well as it should, which can lead to resistance or bad side effects to medications, sometimes even liver damage.
However, some herbal therapies may be effective in reducing side effects such as nausea and poor appetite, but still should be taken with caution. Herbs can also enhance the flavour of foods – increasing food intake. But some also have side effects and negative interactions with ART. Mostly, avoid taking herbals in pill form – best to take in natural state (teas or adding herbs to food). As some pill-form herbal treatments are expensive, encourage clients to spend money on food first.
Garlic supplements and Saquinavir – leads to decreased effectiveness of ARV.

8. Food and Medication Interactions
Food (affects) Medication absorption, metabolism, distribution, and excretion
Medication (affects) Nutrient absorption, metabolism, distribution, and excretion
Medications’ (affects) Food intake
side effects and nutrient absorption
Medications + (causes) Unhealthy side effects
certain foods or therapies
Foods and medications interact in various ways. First review the definition of absorption, metabolism, distribution, and excretion. Absorption is when the food or medication goes through the GI tract lining and enters the blood stream. Metabolism is the process that food or medications take to travel through the blood and breakdown in the liver.
Distribution is the process where food or medication is put to use for where it is needed or used. For example, protein from food is used to build cells and muscles so after metabolism, the proteins will be distributed through the body for cells and muscle development. Excretion is the process where extra, unused parts of food or medications leave the body, either through urine or faeces.
Food affects medication absorption, metabolism, distribution, and excretion. Ex: a high fat meal can decrease the absorption of AZT
Similarly, medications affect nutrient absorption, metabolism, distribution, and excretion. Ex: some ARVs (d4t, ritonavir) affect how cholesterol is metabolized, leading to increased risk of heart disease
Medications’ side effects can affect food intake and nutrient absorption. Ex: nausea, vomiting and diarrhoea are very common side effects of most ARVs, and these side effects can lead to a person not eating enough food or not absorbing nutrients they eat. This can lead to malnutrition as well as non-adherence
And, medications plus certain foods or therapies can cause unhealthy side effects. Ex: many ARV’s combined with alcohol are not absorbed well, leading to side effects and resistance due to low bioavailability of the medications.
Clients who have symptoms such as nausea, vomiting, diarrhoea often are not taking their medications correctly or following the proper food regimen’s based on medications. Pills that should be taken with food are often not. If there are no restrictions/recommendations, clients can try to take them with food and then without to see what feels better.
Source: HIV and AIDS: A guide for nutritional care and support, 2nd Edition, Food and Nutrition Technical Assistance (FANTA) Project., Academy for Educational Development (AED), Washington, DC.

9. How Can Diet Help with Medications?
Management of side effects
Enhance flavour of foods
Balanced meals help prevent side effects and promote adherence
Avoid alcohol use with medications
Address food security issues with client
Diet can help with management of side effects by using certain foods to prevent or treat side effects. Management of side effects were discussed in Session 3.
By flavouring foods or using herbs, some foods can be easier to eat or digest, therefore helping the client to eat more.
Having food and enough of a variety of foods can help promote adherence to therapies.
Alcohol use should be avoided with all medications for interaction reasons, but also for social issues, as alcohol is widely consumed in Namibia. Often if someone drinks too much alcohol, then can forget to take their medications. This leads to poor adherence and resistance.
Food security issues should be addressed throughout HIV care to make sure the client has access to food or is being assisted for food access.

10. Pregnant and Lactating Women
More food needed during pregnancy and lactation
Good nutrition status increases effectiveness of HAART/medications and reduces infant low birth weight
In general pregnant and lactating women need more energy and nutrients because they are feeding themselves as well as their baby – this is true whether the mother is HIV positive or not. Needs do not necessarily increase for HIV unless mother is symptomatic.
A pregnant or lactating woman’s needs will increase by about 10% than usual. This translates to adding one more serving of staple energy food to a meal, adding 1-2 teaspoons of oil to a meal or one or two eggs to an already balanced meal. If the meal already consists of only mahangu, other foods (protein, fats, fruits, vegetables) need to be added to make this balanced. Otherwise, any smaller amount of protein or fat will be used for energy and not for its primary function to build the immune system.

11. Infants and Children on HAART
Increased nutrition/energy needs
Greater risk for malnutrition, morbidity (illness) and mortality (death)
Closely monitor growth (weight and height), clinical signs of malnutrition (i.e. wasting, oedema) and feeding patterns
Children on HAART may need extra nutrition since they are at greater risk for malnutrition, illnesses or even death.
Children on HAART need to be closely monitored for growth failure and inappropriate feeding. Severe malnutrition should be treated immediately and, if necessary, concurrent with HAART (as long as the child is stable).
Oftentimes, the taste of HAART can make children want to eat less. Health workers should counsel mothers on this and provide suggestions for making sure that children on HAART are getting enough nutrition.

12. Common Side Effects from Medicines
Nausea, vomiting, diarrhoea
Poor appetite
Changes in taste
Metabolic Changes
Iron Deficiency Anaemia
Liver toxicity
Rash/skin problems
Step 3: Common Side Effects with HAART (Slides 12-17) – 10 minutes
Review common side effects with HAART. Most of these were discussed in Session 2 (refer to Symptom Management Guide, Handout 2.1), except metabolic changes
Liver toxicity should be addressed immediately by the physician. In terms of nutrition, avoid giving iron supplements with liver toxicity. Rash may range from mild to severe. In addition to medical treatments, severe skin problems or ulcers may require micronutrient supplements for better wound healing. If giving high doses of vitamins and minerals, client must be monitored for toxicity symptoms (i.e. liver problems)

13. Metabolic Changes
Lipodystrophy: changes in the way the body makes, uses and stores fat. Two types:
Lipoatrophy: loss of subcutaneous fat (fat under the skin), mostly in arms, legs, buttocks, and face
Lipohypertrophy: fat accumulation, mostly around the abdomen, chest, and behind the neck
Biochemical changes: high blood fat levels, high blood sugar levels
Increases risk of heart disease and diabetes
Explain that metabolic changes are a relatively new side effect seen with people who have been taking HAART for many years. It is a condition with two main components: Lipodystrophy (lipoatrophy and lipohypertrophy) and biochemical changes.
Lipodystrophy: changes in the way the body makes, uses and stores fat. Two types:
Lipoatrophy: lipo = fat; atrophy = dying of (for example, tissues or cells). This term means that a person is losing subcutaneous fat (fat found under the skin), mostly in their arms, legs, face, and buttocks.
Lipohypertrophy: lipo = fat; hypertrophy = accululation. This term means that fat is accumulating in certain parts of the body. In this case, fat accumulates mainly in the centre of the body or abdomen/chest areas.
These two conditions can occur individually or together.
With these metabolic changes, in addition to physical changes in the body, a person on long-term ART can also start to see biochemical changes. These include high blood fat levels and high blood sugar (glucose) levels. An increase in these blood levels can put a person at risk for non-communicable diseases over time, such as heart disease (with high fat levels) and diabetes mellitus (with high glucose levels).

14. Metabolic Changes Associated ARVs
d4T (stavudine)
Possibly other NRTIs
Protease inhibitors and boosted PIs
Early prevention, detection, and treatment are important!
Look for physical signs of lipodystrophy/lipoatrophy
Biochemical monitoring
These metabolic changes are associated with a few specific ART, namely d4T, possibly other NRTI’s and PI’s.
At this point where we don’t know what the rate for metabolic changes is here in Namibia, it is critical to prevent, detect, and treat these changes early by looking for physical signs of lipodystrophy or lipoatrophy and regularly monitoring blood fat and sugar levels.
Another common side effect is wasting syndrome, which was discussed in Session 2. (Slide 20, in the next step, shows a photo of a patient in Haiti before he went on HAART and one year later.) It is important to note that we need to make sure clients have enough food to take with HAART for them to see the most benefit of the medications.
However, in patients whose HIV is being successfully treated and the virus is well controlled, we are seeing a new type of AIDS wasting. Wasting due to metabolic changes causing severe loss of fat often noticeable in specific areas like the face, arms and legs. Sometimes weight loss is sudden with no apparent precursor.
C. Steinberg © ITECH, 2006

15. “Buffalo hump” in HAART-treated patient
Dorsocervical Fat Pad
Photo of what is known as “buffalo hump”, which presents as accumulated fat in the dorsocervical region (behind the neck). This is linked to HAART use in HIV patients.
Photo from Source: Dominic C. Chow, MD, University of Hawaii; Larry J. Day, MD, University of Michigan; Cecilia M. Shikuma, MD, University of Hawaii. Accessed from: on April 18, 2007
Source: Dominic C. Chow, MD, University of Hawaii; Larry J. Day, MD, University of Michigan; Cecilia M. Shikuma, MD, University of Hawaii
“Buffalo hump” in HAART-treated patient

16. Central Fat Accumulation
Photo Courtesy of Dr. Stefan Mauss
Shows central fat accumulation as a side effect of HAART.
NB: This is one example of an extreme case. Even milder symptoms of central fat accumulation can be serious and require further assessment.
Visceral fat accumulation, before ART
Visceral fat accumulation, four months after starting ART
Courtesy of Dr. Stefan Mauss

17. Dietary Considerations for Metabolic Changes
Reduce refined starches (e.g. maize, white bread, pastas, sugar)
Increase fibre from whole grains (e.g. oats, mahangu, brown bread) and fresh fruits and vegetables
Eat more “good fats” from foods like oils, avocado, and nuts and less “bad fats” from butter and deep fried foods
Exercise at least 45 minutes a day
The mechanism of diet and metabolic changes is still not fully known, but some evidence suggests that reducing simple sugars and refined carbohydrates, with an increase in whole grains can help manage metabolic changes. Additionally, these points are important for all persons living with HIV, so this can be recommended for all HIV clients.
Exercise may help manage metabolic changes as well
Before showing Slides 18 and 19, ask participants what they think are important counselling points related to nutrition and HAART before the client starts HAART and while they are on them.
List responses on the flip chart.

18. Counselling Pre-HAART
What are client’s eating habits?
Number of meals per day?
What are common foods eaten?
Any times when food is not available?
Any recent weight loss? How much?
Any current medications (consider modern and traditional medicines)?
What are specific food-medication interactions or common side effects of proposed ART regimen?
Step 4: Counselling Before and During HAART (Slides 18-20) – 10 minutes
Compare participant responses recorded on the flip chart with the information presented in the Slides.
Refer to Handout 3.1 when discussing this Slide.
These are important considerations when counselling a client on ART before they start.
We need to assess the client’s food situation before starting ART to prevent poor adherence and side effects. Patients without adequate access to food should not begin ART until steady supply is available.

19. Counselling During HAART
What is the client’s food-HAART schedule?
What side effects does the client have?
Has the client lost weight since beginning HAART?
Is the client taking other medications or traditional therapies?
If traditional therapies taken: in what form (pill), what is cost, and do these replace meals?
Continue referring to Handout 3.1 and discuss important points to consider regarding nutrition during ART.
Making a food-ART timetable or schedule can help visually see which foods may cause interaction or which times medications should be taken to fit into normal eating habits.
Clients may begin to experience some side effects, so these need to be addressed as soon as possible. Provide the client with counselling on how to manage side effects.
Clients should be monitored for weight loss and continue weighing patient even if they are at a normal weight. Positive reinforcements should be stressed here since a person who hears that they are doing well, health-wise, may be more apt to remain adherent to medications.j
Always ask about other medications or therapies taken and discourage any therapies that seem to replace meals or are very expensive.

20. Weight Gain on Effective HAART and Nutrition Therapy
This was the photo of a man before and 1 year after he received HAART.
In addition to HAART, adequate food intake is essential. In order to succeed on HAART, one must have adequate amounts of the appropriate foods available to them.
Photograph by: David Walton Copyright  2003 Partners In Health
Before HAART
After 1 year on HAART

21. Common HAART Regimens
AZT/3TC/NVP (zidovudine – lamivudine – nevirapine)
AZT/3TC/EFV (zidovudine – lamivudine – efavirenz)
AZT/ddI/INV+r (zidovudine – didanosine – indinavir+ritonavir)
AZT/ddI/LPV+r (zidovudine – didanosine – kaletra)
Step 5: Food and Medication Table Activity (Slides 21-23) – 45 minutes
Present the common HAART regimens listed on the Slide.
Refer to Handout 3.2, Food Effects of HIV Medications.
This list will be used in the following Food and Medication Table Activity (instructions are on this Slide and the next):
Split the class into three to four groups and assign one drug combination to each group. Tell the groups that for the sake of this exercise, we will assume the regimen is to take each medication twice a day, in 12 hour intervals.
For example: the first combination AZT/3TC/NVP would be taken at 7h00 and 19h00 each day. The medications do not need to be taken together, so one can be taken before others, as long as each medication is taken 12 hours from the last dose.

22. Sample Adult HAART Schedule with Meal Plan
Time of Day
Food
Medication
Refer participants to Worksheet 3.1 and refer to instructions for this activity as written on the worksheet as needed.
Explain to the groups that they will pick one person to play the role of the client who will explain all the foods they ate yesterday and the time they ate. The rest of the group will record their food in the food column of the chart. They will then do the same for their medication (use the assigned regimen).
After they have recorded the food and medication with corresponding times, as a group they should discuss the questions on Worksheet 3.1.
Allow participant about 30 minutes to complete the activity.
Then bring the group back together and discuss the activity as a large group (15 minutes). The questions from Worksheet 3.1 are listed on the following Slide (Slide 23).

23. Food and Medication Table Activity
Questions to answer:
Is the diet adequate for the medication regimen this person is taking?
What should be changed, if anything?
What are some side effects with the medications?
What can you tell the client to do to prevent or manage potential side effects?

24. Case Studies Step 6: Case Studies (Slide 24) – 40 minutes
Refer to the Facilitator Guide and Worksheet 3.2 for this activity

25. Key Points
All persons need to have access to healthy food, especially those on HIV medications
Counsel clients on food effects of their medications
Help clients make a food-medication timetable
HIV medications can help a person with HIV live longer, but not without proper nutrition
Step 7: Key Points (Slide 25) – 5 minutes
Review key points as listed and summarise the unit.