Nutrition and HIV/AIDS: A Training Manual Session 6

Transcription

1 Nutrition and HIV/AIDS: A Training Manual Session 6

2 Purpose To provide a general understanding of special considerations for nutritional care and support of HIV-infected pregnant or lactating women or adolescent girls.

3 Session Outline Why focus on women, nutrition, and HIV? Nutritional implications for the HIV-positive pregnant and lactating woman or adolescent girl Nutritional requirements of the HIV-positive pregnant and lactating woman or adolescent girl Nutrition care and support for the HIV-positive pregnant and lactating woman or adolescent girl Role of nutrition care and support Goals of nutrition care and support Components of nutrition care and support Issues and challenges in nutrition care and support

4 Why Focus on Women, Nutrition, and HIV?

5 HIV has the face of a woman African women are infected for every 10 African men (WHO/UNAIDS) Over 50% of adults living with HIV/AIDS in sub- Saharan Africa are women years old 15 million women in Sub-Saharan Africa are living with HIV

6 HIV Prevalence in sub-saharan Africa Number of men and women years old living with HIV/AIDS, end of Adults Women Men Source: UNAIDS 2002

7 Vulnerability of Women and Young Girls Antenatal HIV-positive rates are up to 50% Women and young girls face greater risk of infection than men Biological factors Limited access to economic opportunities Limited access to health care increases risk factors Diminished social status compromising ability to chose healthier life strategies Women are responsible for caring for the sick when they themselves may also be infected

8 Women, Nutrition, and HIV Good maternal nutrition is important for women s health and reproduction and infant survival and development Malnourished women are at higher reproductive risk and have poorer pregnancy outcomes than well-nourished women In Africa endemic malnutrition is complicated by the AIDS epidemic

9 Malnutrition and HIV Work in Tandem Malnutrition Weakens the immune system Increases vulnerability and susceptibility to infection Increased nutrient requirements HIV infection

10 Nutritional Implications for the HIV-Positive Pregnant or Lactating Woman or Adolescent Girl

11 During Pregnancy Malnutrition increases maternal morbidity and mortality Zinc and vitamin A deficiencies increase the risk of reproductive tract infections Low calcium intake increases the risk of pre-eclampsia and high blood pressure Iron deficiency reduces resistance to disease, causes fatigue, and reduces productivity Anemia increases risks of prolonged labor and death from hemorrhage

12 During Pregnancy, Cont. Malnutrition affects birth outcome Leads to intra-uterine growth retardation and low birth weight Decreases nutrient stores for later development Increases neonatal mortality and morbidity Malnutrition may increase the risk of MTCT Vitamin A deficiency associated with increased viral load in blood, genital secretions, and breastmilk Low hemoglobin associated with increased risk of preterm delivery and low birth weight risk factors for MTCT

13 During Pregnancy, Cont. Micronutrient supplementation for HIV+ women has NOT reduced MTCT, but HAS produced other benefits Vitamin A supplementation studies have shown reduced pre-term delivery (South Africa) and improved birthweight, neonatal growth, and reduced anemia (Malawi) Multivitamin supplements increased weight gain in pregnancy and reduced risk of fetal death, low birth weight, and pre-term delivery <34 weeks (Tanzania)

14 During Lactation Increased nutritional demands of lactation may increase weight loss, a risk factor for reduced survival in HIV infection Breastfeeding HIV+ mothers more likely to die within 2 years post-delivery (Kenya) No increased risk of mortality (South Africa) Further research needed on impact of breastfeeding on maternal HIV disease progression WHO does not recommend daily maternal vitamin A supplementation during lactation, which may increase the risk of MTCT through breastfeeding

15 For HIV-Positive Pregnant or Lactating Adolescents Young maternal age (11-18) increases needs for nutrient Needs for adolescent growth Needs for fetal growth and development HIV infection further increases nutrient needs Needs for adolescent growth Needs for fetal growth and development Increased requirements from HIV infection

16 Nutritional Requirements of the HIV-Positive Pregnant or Lactating Woman or Adolescent Girl

17 What Is Known Physiological changes during pregnancy and lactation require extra nutrients For adequate gestational weight gain For growth of the developing fetus For milk production HIV causes malabsorption and excess nutrient loss that further increase nutritional requirements Nutrition requirements for pregnancy superimposed on requirements for HIV Women s nutritional status influences their health and may affect risk of MTCT HIV-positive women are at greater nutrition risk

18 What Is Known, Cont. Nutritional requirements for HIV-positive pregnant and lactating women Vulnerability to iron deficiency (80% of pregnant women in sub-saharan Africa are anemic) Research studies have shown multivitamin supplements are associated with health

19 What Is Not Known Increased requirements for energy, protein, and other nutrients for the HIV-positive pregnant and lactating woman 2003 WHO technical consultation on HIV and nutrition found no data to suggest increased energy requirements for HIV-infected pregnant or lactating women compared with non-infected pregnant and lactating women; stated that increased energy needs in pregnancy and lactation were the same as for other infected adults

20 Comparison of Nutritional Risks HIV+ mother Increased energy, protein and other nutrients secondary to demands of pregnancy or lactation Increased energy and micronutrient needs secondary to HIV infection Increased risk of opportunistic infections and therefore of malnutrition Increased risk of weight loss and delivery of a low-birth weight baby because of HIV infection Increased risk of inadequate dietary intake and therefore of malnutrition because of depression, isolation, or stigmatization Increased risk of MTCT with poor nutritional status and through breastfeeding HIV- mother Increased energy, protein and other nutrients secondary to demands of pregnancy or lactation

21 Recommended Energy and Protein Requirements in Pregnancy FAO/WHO 1985 Institute of Medicine 1990 Energy requirements 285 kcal/day above non-pregnant levels if physical activity is maintained 200 kcal/day above non-pregnant levels if physical activity is reduced 300 kcal/day above non-pregnant levels Protein requirements 3.3g/day of high quality protein throughout pregnancy 60g/day of protein

22 Recommended Energy and Protein Requirements during Lactation FAO/WHO 1985 Energy requirements Extra 500 Kcal/day above non-lactating levels (increase if breastfeeding more than one child) Protein requirements Extra 16g/day for the first 6 months of lactation, 12g/day for the second 6 months, and 11g/day thereafter Source: FAO/WHO/UNU Energy and protein requirements. Report of a Joint FAO/WHO/UNU Expert Consultation. Geneva.

23 Recommended Micronutrient Supplementation WHO/UNICEF recommend iron and folate during pregnancy and lactation Where anemia prevalence is < 40 % 60mg iron + 400mcg folic acid daily for 6 months in pregnancy If started late, extended 6 months post-natally If impossible, dose increased to 120mg iron in pregnancy Where anemia prevalence is > 40% 60 mg iron mcg folic acid daily for 6 months in pregnancy Continued 3 months post-partum Daily multivitamin supplement where available

24 Nutritional Requirements for HIV+ Pregnant and Lactating Women Increased energy requirements for HIV-infected pregnant and lactating women are the same as for other HIV-infected adults 10% increase in energy requirements during asymptomatic HIV infection 20%30% increase during symptomatic HIV infection The additional increment in energy is added to the basic energy requirement for age/activity/weight, not to the additional calories for pregnancy or lactation

25 Nutritional Requirements for Healthy Adolescent Pregnancy What is known Nutritional risk increases because of combined need of growing adolescent and growing fetus Energy needs should be considered for normal growth of the teenager and weight gain needs for pregnancy An extra 300 kcal/day are needed in the 2nd and 3rd trimesters Younger adolescent girls (13-16 years old) may need even higher energy intakes

26 Nutritional Requirements for Healthy Adolescent Pregnancy What is known, cont. Pregnant adolescent girls should not eat less than 2,000 kcal/day (as per individual energy requirements) Protein requirements increase for the normal growth and development of the teenager and of the fetus Needs for iron, folic acid, and zinc increase (a multivitamin supplement may help meet these increased needs)

27 Nutritional Requirements for HIV+ Pregnant and Lactating Adolescent What is not known Increased energy needs (as with the adult HIVpositive pregnant and lactating woman) NO current recommendations for increase in protein requirements

28 Role of Nutrition Care and Support for the HIV- Positive Pregnant or Lactating Woman or Adolescent Girl

29 Importance of Nutritional Well-being for Pregnancy and Birth Critical for an uncomplicated pregnancy, positive birth outcome, and adequate quality and quantity of breastmilk production Increased nutritional risk and hence increased risk of morbidity and mortality in pregnancy and poor pregnancy outcome in HIV-infected women Increased risk of vertical transmission of HIC if HIV-positive mother has poor nutritional status during pregnancy

30 Role of Nutrition Care and Support Studies have shown that clinical outcome of HIV is poorer in people with compromised nutrition Improving nutrition can help prevent weight loss, strengthen the immune system, and delay HIV disease progression, allowing the mother to remain productive Nutrition care should be part of a comprehensive program that helps the HIV-infected person and affected family members

31 Purpose of Nutrition Care and Support During pregnancy To meet the demands of expanded blood volume, growth of maternal tissues, developing fetus, and loss of maternal tissue at birth To prepare for lactation During lactation To meet specific nutrient needs to optimize maternal post-natal nutritional status, quality and quantity of breastmilk production, and infant growth and development

32 Goals of Nutrition Care and Support for the HIV- Positive Pregnant or Lactating Woman or Adolescent Girl

33 Goals of Nutrition Care and Support Improve nutritional status Maintain weight and prevent weight loss Preserve lean body mass Ensure adequate gestational weight gain Ensure adequate nutrient intake Improve diet and eating habits Replenish stores of essential nutrients Prevent food-borne illness Encourage good hygiene and water and food safety Enhance quality of life Treat opportunistic infections Manage symptoms affecting food intake

34 Components of Nutrition Care and Support for the HIV-Positive Pregnant or Lactating Woman or Adolescent Girl

35 Nutrition Assessment and Counseling Nutrition screening and assessment Nutrition history Physical assessment Medical history Medication profile Biochemical data Psychosocial issues Nutrition education and counseling Adequate diet and eating habits Management of common dietary problems in HIV

36 Food Safety and Hygiene Wash hands before food handling, after using the toilet, after changing baby s nappy Wash fruit and vegetables before cooking and serving Drink and use only boiled water Do not eat raw eggs or foods containing them Do not eat moldy, spoiled, or rotten foods Cover all food items when not in use Store food away from insects and animals Keep food preparation surfaces and utensils clean Ensure all food is cooked thoroughly Serve food immediately after preparation and do not store cooked food Avoid contact between raw and cooked food Use a cup rather than bottles with teats to feed infants

37 Management of Diet-Related HIV Problems Use diet and medication strategies to control anorexia, nausea, vomiting, diarrhea, constipation, bloating, mouth or throat sores, fever, malabsorption, fatique, and taste alterations Encourage and use safe traditional therapies to manage symptoms and improve intake Ensure adequate energy and protein to prevent malnutrition through small, frequent meals and highprotein energy foods with and between meals Counsel on food and drug interactions Modify food to manage symptoms and increase intake through pureed, minced texture, boiled instead of fried food, and flavor enhancers such as herbs and spices

38 Physical Activity, Safer Sex, and Psychosocial Support Promote and encourage physical activity to improve body composition, stimulate appetite, and increase energy Promote safer sex and reproductive health practices such as use of condoms Provide psychosocial support Encourage peer support where available Counsel and support to cope with stigma, especially if not breastfeeding, and disclosure of HIV status to partner, family, and friends

39 Optimal Antenatal and Post-natal Care Ensure adequate weight gain during pregnancy Start early nutrition intervention to minimize impact of HIV on nutritional status Reduce risk of anemia and low birthweight Provide iron, folic acid, and multivitamin supplements Provide antimalarial prophylaxis and deworming Promptly treat and manage conditions that affect food intake and risk of PMTCT Promote safer sex practices Offer VCT and provide ARVs if available

40 Infant Feeding Counseling Counsel on infant feeding options and risks Support mothers feeding decisions Provide nutrition support for breastfeeding women

41 Medication and ARV Therapy Manage side effects Maintain good food intake Ensure adherence to medications and ARV therapy Consider food-drug and drug-nutrient interaction Properly counsel pregnant and lactating HIV+ woman or adolescent girl on use of medications

42 Issues and Challenges for Nutrition Care and Support of the HIV-Positive Pregnant or Lactating Woman or Adolescent Girl

43 Greatest Impact of Nutrition Improvement Early in HIV Disease Most people do not know they are HIV positive until they have advanced disease Greater availability of and access to counseling and testing will let women know their status and deal with it more effectively Improving access to treatment for HIV or opportunistic infections may increase willingness to be tested for HIV

44 Stigma and Discrimination Women may for social and cultural reasons have more limited access to care and support services Family resources are more likely to be used to buy medication and care for ill males than females

45 Access to Food Food access is a major challenge for people living with HIV.AIDS in Africa Food insecurity increases the vulnerability of women and young girls to HIV infection by diminishing social status and compromising ability to choose safer and healthier life strategies Lack of adequate food and nutrition complicate the management of HIV/AIDS

46 Gender Challenges of HIV Vulnerable social status and lack of legal rights (in several countries, rural women whose husbands had died of AIDS forced to engage in commercial sex to survive because no legal rights to their husband s property, increasing their food insecurity and risk of malnutrition) Changes in women s rights and empowerment needed to reverse the spread of HIV

47 Responsibility for Food Crops In most cases planting of food crops falls to women AIDS-affected households may plant less food or replace labor-intensive but nutritious crops with less nutritious but more profitable crops, contributing to food insecurity and malnutrition, especially in nutritionally vulnerable pregnant and lactating women and children

48 HIV/AIDS Adds to an Already Heavy Burden Women are workers, caregivers, educators, and mothers Women are also usually responsible caring for the sick, even when they are sick themselves Women s legal, social, and political status makes them more vulnerable to HIV/AIDS