1. HIV/AIDS and Nutrition
Module 18
This presentation is approximately 30 minutes.
Suggest that you have a local resource person (facilitator) to present the local HIV situation to provide a context. Most countries believe that HIV/AIDS id not an issue for them.

2. Learning objectives
Be able to identify the changing nutritional requirements of people living with HIV and how these could be managed in emergencies
Be aware of the complex issues surrounding targeting of people living with HIV in emergencies
Understand the issues linked to breastfeeding for HIV-positive mothers in emergencies
Have enough knowledge to understand the importance of key services for the treatment and care of people living with HIV in emergencies to maintain nutritional status
Understand the importance of good hygiene, water and sanitation for people living with HIV. 2

3. The Global AIDS epidemic
Since the beginning of the epidemic, almost 60 million people have been infected with HIV and 25 million people have died of HIV-related causes
In 2008, some 33.4 million people living with HIV, 2.7 million new infections and 2 million AIDS-related deaths
In 2008, around children were born with HIV, bringing to 2.1 million the total number of children under 15 living with HIV
Young people account for around 40% of all new adult (15+) HIV infections worldwide
Sub-Saharan Africa is the region most affected and is home to 67% of all people living with HIV worldwide and 91% of all new infections among children
In sub-Saharan Africa the epidemic has orphaned more than 14 million children. 2

4. Humanitarian crises and HIV and AIDS
Factors that may accelerate the spread of HIV in emergencies include:
Rape and sexual violence
Mass displacement of people
Severe impoverishment leading to transactional sex for survival
Breakdown in normal health and social services leading to reduction in the availability of:
Voluntary counselling and testing for HIV
Reproductive health options
Treatment for Sexually Transmitted Infections (STIs)
Antenatal care
Antiretroviral treatments for breastfeeding HIV+ve women 2

5. HIV and AIDS programming
The challenges faced by humanitarian workers, governments and civil society fall within all the 3 pillars of HIV/AIDS programming, namely:
Prevention
Health care and treatment
Support and care
Prevention – condoms, counselling, infant and young child feeding counselling and support, etc
Health care and treatment - ARTs, opportunistic infections treatment, nutritional support including micronutrient supplements
Support and care – psychosocial support, family and community support, etc 2

6. 2010 Inter-Agency Standing Committee Guidelines
The 2010 IASC guidelines for addressing HIV in humanitarian settings action framework lists 9 sectors into which HIV should be integrated:
Awareness raising
Health
Protection
Food security
Education
Shelter
Camp coordination
Water, sanitation, and hygiene
The workplace
Earlier guidelines focused on avoiding stigmatisation
The 2010 guidelines emphasise the need for coordination of existing and fragmented HIV support groups to provide targeted nutritional support, food security, and livelihood support. 2

7. What is the link between HIV and AIDS and Nutrition?
One of the most common signs of HIV progression is weight loss
Unexplained weight loss (>10% of body weight) is one of the signs used to indicate that a patient is moving from the asymptomatic phase towards AIDS
There are 2 patterns of weight loss:
First pattern is a slow gradual decline in weight over time with HIV infection
Second pattern is a rapid and drastic weight loss often associated with a serious infection 2

8. Link between HIV and AIDS and Nutrition
Early detection of HIV provides an opportunity to build up good nutritional status and healthy eating habits
Good nutrition is a form of immune protection, especially important in the presence of HIV
People living with HIV may reduce the amount of food they consume due to the following factors:
Sores in the mouth, throat, and digestive tract
Persistent nausea, vomiting, diarrhoea, or stomach pains
Depression which reduces appetite
Economic problems due to loss of income or lack of access to adequate food
Tiredness making food preparation slow or difficult
People living with HIV may also have poor absorption of nutrients from food consumed due to:
Diarrhoea
Intestinal tract infection
Medications side effects
(Anaemia)

9. Link between HIV and AIDS and Nutrition (2)
The metabolism of a person living with HIV is altered
In the asymptomatic phase an additional 10% of energy is required
As a person moves into the symptomatic phases, the energy requirement goes up 20-30% more
Children in symptomatic phases require % more energy than expected by age and weight
 If nutritional needs are not met, the body is more susceptible to infections and may take longer to recover from minor illnesses
This leads to a cycle of more weight loss, more vulnerability, and worsening illness

10. Nutrient requirements for HIV+ in relation to Normal Dietary Requirements
Population Group
Recommendations*
Energy
Asymptomatic HIV+ Adults
Adults with symptomatic HIV infections (including pregnant and lactating women)
Asymptomatic HIV+ children
Children experiencing weight loss regardless of HIV status
Children with severe acute malnutrition
Increase of ~10%
Increase ~20%
Increase of %
No change from WHO guidelines
Protein
All population groups
No change indicated to date (10-12% of total energy intake)
Fat
Individuals who are HIV- or HIV+ but not taking antiretroviral drugs
No change indicated to date (at least 17% of total energy intake)
Micro-nutrients
No change indicated to date. Micro-nutrient intake at RDA is recommended
*Adapted from WHO, 2003: Nutrient requirements for People Living with HIV/AIDS, Report of technical consultation. Geneva, WHO. Refer to this document for details and discussions on nutrient requirements

11. Vicious Cycle of Malnutrition and HIV
Source: Adapted from RCQHC and FANTA 2003
Poor Nutrition
resulting in weight loss, muscle wasting, weakness, nutrient deficiencies
Increased Nutritional needs
Reduced food intake and increased loss of nutrients
Increased vulnerability to infections e.g. Enteric infections, flu, TB hence Increased HIV replication, Hastened disease progression Increased morbidity
Impaired Immune System
Poor ability to fight HIV and other infections, Increased oxidative stress
HIV

12. Nutrition during pregnancy and early infancy for those affected by HIV
Condoms and ART supplies particularly for pregnant women are an important part of integrated HIV and nutrition planning
PLW with HIV require the same increase in foods and added micronutrients as HIV-ve pregnant women, plus an additional 10% to maintain their health in the context of HIV infection 2

13. Nutrition during pregnancy and early infancy for those affected by HIV (WHO, 2010)
The best way to approach nutritional care and prevent mother-to-child transmission of HIV:
Appropriate health care during pregnancy (with ART)
Breastfeeding exclusively in the first 6 months and continue up to at least a year
Replacement feeding if acceptable, feasible, affordable, sustainable and safe (AFASS)
Asymptomatic HIV positive lactating women require the same increase in rations and micronutrients as HIV-ve lactating women, plus an additional 10% for maintaining health in the context of HIV
Lactating women should be supported with good nutrition and access to adequate clean water supplies in order to maintain breastfeeding through at least the first year of the infant’s life.
One reason that an HIV positive woman may stop breastfeeding early is her own illness, so good nutrition and health maintenance is important for both mothers and babies. 2

14. Nutrition during childhood for those affected by HIV
After the first year of life, HIV exposed but uninfected children should transition to family foods with animal protein, particularly milk
Beyond the first year of life, children known to have contracted HIV should continue to breastfeed up to 24 months of age and beyond
In this case, breast milk offers no additional risk, and provides the best source of nutrition
Complementary foods should be added to the diet at 6 months to provide energy, nutrients, and dietary diversity.
This is an early transition point in many cultures, and they may require some additional nutritional support in terms of animal-based proteins, especially milk, that they would otherwise be receiving in breast milk. These are children vulnerable to acute malnutrition because of their early weaning. 2

15. HIV/AIDS and Nutrition in emergencies
8 critical HIV/AIDS and nutrition-related activities in emergencies
Integration of HIV into all aspects of emergency care – prevention, education, health, basic services, planning and management
Targeted food support
Maternal and infant health and feeding
Treatment and care of HIV
Treatment of severe acute malnutrition
Support networks, including livelihood support and HBC
Food hygiene, sanitation, water, shelter
Protection 2

16. HIV/AIDS and Nutrition in emergencies
Integration of HIV into all aspects of emergency care –
prevention, education, health, basic services, planning and management
Mainstreaming HIV programming into emergency coordination and management can help to prevent the transmission of HIV and uphold the human rights of those living with HIV
The type of emergency and the stage of the emergency will influence the HIV/AIDS and nutrition interventions that need to be undertaken (analysis to be conducted)
The ideal is to integrate HIV into existing food assistance and livelihood support, and integrate food assistance, security, nutrition, and livelihood support into HIV-related projects and activities.
The 2 programming activities can strengthen one another. 2

17. HIV/AIDS and Nutrition in emergencies
Targeted food support
Household food insecurity should be the main (initial) targeting principle, regardless of whether HIV status is known
HIV prevention and sensitization activities should be linked to large-scale food distribution
Particular attention should be given to the identification of households that may be vulnerable because of the presence of HIV or AIDS:
child or elderly headed HH
orphans hosting HH
HH with sick members, etc.
Targeting people living with HIV/AIDS directly may be possible
if there is no stigma or discrimination;
if the targeting does not increase stigma;
if the targeting does not unjustly exclude non affected households.
There are many issues surrounding targeted food support, principally:
Should there be targeted food support?
What should the food support consist of?
How should it be carried out? 2

18. HIV/AIDS and Nutrition in emergencies
Targeted food support
Food rations should be specially designed and distribution should consider issues such as distance to cover, capacity to cook, to eat, etc.
Quality- balanced diet particularly important (preparation, consumption and digestibility)
Quantity- increase of 10% in energy required to maintain body weight
in asymptomatic HIV infected adults, can rise to 20-30%
for symptomatic adults and % for children with acute weight loss and infection
Safe access to food- women and girls should have direct access to food distributions and rations - protection

19. HIV/AIDS and Nutrition in emergencies
Maternal and infant health and feeding
Continuation of breastfeeding recommended
ART reduce rate of transmission from mother-to-child during pregnancy from 40% to 10%, and also reduce the risk of transmission through breastfeeding
HIV testing should then be offered to all mothers:
to determine status
to obtain and dispense appropriate ART treatments to breastfeeding mothers as a complement to breastfeeding
(testing of infants only reliable after 18 months)
Guidelines available for feeding non breastfed infants. 2

20. HIV/AIDS and Nutrition in emergencies
Treatment and care of HIV
The treatment based on ART and cotrimoxazole (for opportunistic infections) helps nutrition by:
improving appetite
utilisation of nutrients by the body
reduction of opportunistic infections
Medication often combined with Food by Prescription (FBP) programmes to increase adherence
Protection and prevention is to be ensured with safe procedures at health facility level, access to condoms, access to post exposure prophylaxis, etc. 2

21. HIV/AIDS and Nutrition in emergencies
Treatment of severe acute malnutrition
Treatment remains the same as for non HIV children, with addition of cotrimoxazole
SAM cases and their caregivers should be encouraged to take voluntary testing and counseling on HIV
3 care plans for HIV positive children include:
for those growing well (review every 2-3 months)
for those with poor weight gain (regular visit and support)
for the severely malnourished ones (treatment) 2

22. HIV/AIDS and Nutrition in emergencies
Support networks, including livelihood support and Home based care (HBC)
A functioning HBC system provides a safe channel for resources to households with chronically sick members and provide:
Blended fortified foods or fortified cereals ± food basket
RUF or LNS to decrease the preparation time for people with limited appetite
Cash benefits for the purchase of additional foodstuffs
Or the provision of services:
Monitoring of weight and health status
Individual nutritional assessments
HBC limits the risk of opportunistic infections when people with weakened immune systems are not required to wait in health care centres 2

23. HIV/AIDS and Nutrition in emergencies
Support networks, including livelihood support and Home based care (HBC)
HBC can also be used for provision of livelihood support such as:
Dietary diversity support with availability and access to tools, fertilisers, and improved variety seeds
Labour-saving tools adapted to local conditions
Alternative income-generating activities compatible with new activity constraints
Skill building programmes such as junior farmer fields and life school programmes to combine livelihood support with skills education for children who are unaccompanied, orphaned, or made vulnerable by the illness of family members. 2

24. HIV/AIDS and Nutrition in emergencies
Food hygiene, sanitation, water, shelter
These are critical in emergency:
Food Hygiene: avoid contamination during cooking or storage
Sanitation and water availability: latrine construction, control of stagnant water, promotion of hand washing, quality and quantity of water supplies, distance to water
Shelter: safety and security of sites, integration of HIV prevention into shelter programmes 2

25. HIV/AIDS and Nutrition in emergencies
Protection
Gender inequalities are common in emergencies, increasing the vulnerability of women to HIV
Vulnerable households are also common in high HIV prevalence contexts:
Child-headed households
Households with no adult male members
Elderly headed households
Orphans without family
Households hosting orphans
HIV-positive people who are suffering from discrimination or alienation 2

26. HIV/AIDS and Nutrition in emergencies
Protection (2)
Important policy points that should be in place to ensure the rights of individuals and families living with HIV:
Monitor allegations of HIV-related rights violations (and change program if violence associated to its design)
Ensure HIV service provision respects human rights, including the right to privacy. Use of alternative vulnerability criteria for programmes is recommended
HIV testing should not be mandatory, and all HIV testing should be under confidential conditions, with informed consent and counseling according to international standards
Establish protection for women and girls.
Protect orphans and unaccompanied, separated, and other vulnerable children and youth.
Develop programmes addressing gender based violence. 2

27. Key messages
HIV should be integrated into all aspects of the emergency management planning and response.
People living with HIV have increased nutritional needs in terms of energy requirements.
People living with HIV should be monitored regularly for weight loss which may be a sign of decreased intake or disease progression.
Steps can be taken to reduce the rate of transmission of HIV from mother to child with counselling on infant feeding and ART (antiretroviral therapy). Food/nutrition support may be needed.
Services for HIV care should be established as a priority. These include provision of ART and cotrimoxazole and VCT (voluntary counselling and testing) facilities.
All severely malnourished children require therapeutic care. HIV positive children should be regularly assessed and assigned to appropriate nutritional care plans.
Home based care (HBC) programmes and livelihood support programmes are important for improving the long-term food security status of HIV affected families.
People living with HIV are prone to infections, so access to clean water, appropriate food hygiene and sanitation are a key part of the emergency response for these people/families.
Targeted policies and practices are required to protect the rights and ensure the safety of people living with HIV as well as those at risk of contracting HIV. 2