Human Immunodeficiency Virus (HIV): Nutritional Considerations

Nutritional issues in HIV infection relate to macronutrient and energy needs, lipid disorders, and micronutrient adequacy.

Macronutrient and Energy Needs

HIV infection can trigger a chronic–inflammation, wasting syndrome with increases in protein turnover and energy requirements. Studies of asymptomatic HIV–infected men showed elevated protein breakdown, protein synthesis, and resting energy expenditure, compared with non–HIV–infected individuals. Compensatory increased energy intake can help prevent wasting. Nonetheless, wasting is common, despite HAART.¹⁰

Protein intake is associated with decreased lean body mass, loss of which is strongly associated with disease progression and death in HIV–positive persons.¹¹ A review of available evidence noted that protein requirements of 1.0 to 1.4 grams/kg are indicated for maintenance of lean mass, and 1.5 to 2.0 grams/kg for anabolism.¹²

Protein supplementation with amino acids (L–arginine, L–glutamine) and related compounds (e.g., beta–hydroxy beta–methylbutyrate, a metabolite of leucine) has a significant anticatabolic effect in HIV–positive persons.^13–16 However, additional clinical trials are required before these supplements can be routinely recommended.

Unless they are obese, patients should not be encouraged to lose significant amounts of weight. Studies have consistently shown that HIV–infected patients with a body mass index (BMI) of >25 have higher CD4+ cell counts, decreased risk of viral progression, and decreased mortality compared with their thinner (BMI <25) counterparts. This relationship may be explained by the elevated leptin production in heavier persons, which supports CD4+ cell proliferation.¹⁷ Loss of excess weight may be helpful, however, for overweight patients on HAART whose risk factors for heart disease and diabetes have been elevated by the therapy.¹⁸

Diet and Lipid Disorders

A diet that addresses cardiovascular risk factors is appropriate for patients with HIV. Individuals with HIV were observed to have disturbances in lipid metabolism and insulin resistance prior to the advent of protease inhibitors. However, these medications appear to exacerbate this tendency, even in those without HIV infection. Medication–related decreases in the catabolism of both apoB and nuclear sterol regulatory element binding proteins in the liver and adipocytes bring about increases in fatty acid and cholesterol biosynthesis, insulin resistance, and lipodystrophy. As a result, 10% to 50% of patients on protease inhibitors have hypercholesterolemia, and 40% to 80% of these individuals have hypertriglyceridemia. Although prospective studies do not indicate that this situation leads to increased cardiovascular risk, retrospective analyses found significantly greater risk for myocardial infarction in users of protease inhibitors. Substitution with reverse transcriptase inhibitors does not appear to provide lipid–lowering benefits.¹⁹

Micronutrient Adequacy

Although further study is required, preliminary evidence reveals that higher intakes of fruits, vegetables, and juices increase T cell proliferation,²⁰ or reduce CD38+/CD8+ count, a marker of disease progression.²¹ Fruits and vegetables also provide many nutrients that are deficient in persons with HIV and help reduce the oxidative stress that may occur as a side effect of HAART.²²

Nutrient supplements may be helpful, but study findings are equivocal. Low blood concentrations of many micronutrients are common in HIV–positive individuals and are associated with disease progression and increased mortality.²³ Although some reviews suggest that multivitamin supplements reduce morbidity and mortality,²³ others have found no such advantage.²⁴ Preliminary evidence suggests that selenium supplementation (200 mg/day) may reduce the need for hospitalization by lowering the frequency of opportunistic infections.²⁵ Magnesium deficiency has also been found in roughly 60% of HIV–infected individuals.²⁶ However, routine magnesium supplementation is not recommended except for persons on foscarnet, which frequently causes hypomagnesemia.²⁷ Future clinical trials may determine the impact of micronutrient supplementation on HIV and disease outcome.

Orders

See Coronary Heart Disease chapter.

Nutrition consultation to assess protein requirements.

Exercise prescription.

What to Tell the Family

HIV infection is not currently curable, but progressive immunosuppression and life–threatening, opportunistic infections can be greatly diminished through a combination of medications and a healthful diet. Emotional support from family, friends, and community, and also psychotherapeutic treatments, may provide additional immune benefits for persons with HIV. Family members can encourage healthy lifestyle changes through diet, regular exercise, and abstinence from tobacco and alcohol.