HIV’s high nutritional toll
"In the past there was always an adult around to do the work - to plant seeds and plough the fields. Now, with one in four adults in the region HIV-positive, many people are too sick to work, or have already died, and it is the children, some as young as eight or nine, who are left to cope alone.” – UNICEF Goodwill Ambassador Roger Moore in Zambia.
Africa’s experience of HIV/AIDS over the last 10 years has diverged so dramatically and terrifyingly from that of industrialized countries. Any infection thrives in conditions of poverty, undernutrition, poor health care, low levels of literacy and unsafe water. It is as true of HIV/AIDS as it is of tuberculosis and measles.
The HIV/AIDS pandemic, combined with drought, floods, soaring food prices, decades of conflict, economic decline and cuts in social services, have overwhelmed families in many countries, particularly in Eastern and Southern Africa. The crisis in high HIV prevalence and natural disaster prone countries in Southern Africa has shown how far the coping mechanisms of communities and extended families have deteriorated due to HIV/AIDS. At one point most could survive the periodic droughts or floods and “bounce back”. Now, vulnerable families affected by HIV/AIDS are chronically unable to meet basic household food needs adequately and natural disasters push them over the edge.
Undernutrition rates are increasing as a result of these multiple threats. The link between food and nutritional security and HIV and AIDS is bi-directional. HIV/AIDS can increase the risk of food and nutrition insecurity and food insecurity can increase vulnerability to HIV infection and hasten the progression from infection to illness. Lack of access for all members at all times to have enough food leads to worse health outcomes across a range of diseases, including HIV. It has been reported that nearly half of people with HIV living in poor urban areas have high prevalence of food insecurity.
HIV/AIDS negatively impacts on a person’s nutritional status in different ways: insufficient dietary intake, malabsorption and diarrhea, and impaired storage and altered metabolism. HIV/AIDS results in reduced food intake and utilisation by the body of the nutrients, while simultaneously the nutritional needs of people living with HIV/AIDS are increased because the body has to fight the virus and opportunistic infections. As little as 3-5% weight loss has been associated with mortality. Low body mass index (BMI) at ART initiation is also associated with increased mortality in HIV-infected adults. Opportunistic infections like diarrhoea and tuberculosis take their toll and patients become ever thinner. In some hospitals in Southern African countries, more than half of the children admitted for treatment of severe acute malnutrition test positive for HIV, and in some HIV/AIDS treatment services, more than half of the patients – adults and children - are found to be in need of food and nutrition support. Body mass index (BMI) and weight gain is directly linked to mortality ratio at 3 and 6 months on ART (Madec et al, AIDS 2009).
As HIV/AIDS grows more severe, families face decreasing labour power. Adults become ill or die or have to provide increasing care for ill relatives or orphans. Such factors reduce their capacity to work on the land or to earn a wage. Nutrition insecurity can also make the HIV/AIDS situation worse. If a nutrition emergency persists, it can generate further social displacement, disrupting education and health systems, spurring migration, and worsening the sexual exploitation of women and children – all factors that favour the further spread of HIV/AIDS.
More than 3.4 million children under 15 years of age were estimated to be living with HIV/AIDS in 2010, and without treatment almost 50 per cent of infected infants will die before age two. As of December 2010, about 456,000 children globally were receiving antiretroviral therapy, up from 354,600 children in 2009 and 75,000 in 2005.Our neighbours are not like before – they have distanced themselves. They should be distancing themselves from the virus, not from us”. Ammanuel, 13, orphaned by AIDS, Ethiopia [SOWC 2002].
This crisis in Africa has underscored the dire nutritional needs of all children who are HIV positive or affected by HIV/AIDS, such as orphans and those living in households with infected family members. More than 15 million children under the age of 18 have been orphaned by AIDS and many are left to fend for themselves. Many other children live with HIV-infected parents who can no longer provide food for their families. Orphans are often the hardest hit in the household, and studies have shown they suffer much higher rates of undernutrition than the general population. For example, in one study in Mozambique, overall stunting prevalence in drought-affected areas was 37 per cent, while among maternal orphans the rate of stunting was 56 per cent.
Another challenge is that the health services in many of the highly affected countries struggle to cope with the large numbers of sick and undernourished patients, and only a small proportion of those in need are reached.
UNICEF’s priorities concerning nutrition and HIV/AIDS
Fighting HIV/AIDS is one of UNICEF's five organizational priorities. Apart from focusing on reducing the transmission of HIV from mother to child, we are now paying much more attention to the nutrition, care and support of those who are HIV positive or affected by HIV/AIDS such as adults living with HIV and orphans and children living in households where family members have HIV. HIV-positive pregnant and lactating women are a vulnerable population group that also needs special nutritional care and support.
First, we are providing guidance and training on nutrition programming for people infected and affected by HIV, including nutritional assessment and counseling of those with HIV/AIDS, multimicronutrient supplementation and managing the dietary implications of taking anti-retroviral (ARV) drugs.
Another of UNICEF’s priorities is to support therapeutic and supplementary feeding of people living with HIV who are suffering from severe and moderate acute malnutrition respectively. The approach to management of acute malnutrition involves both inpatient care and community-based management. The latter is an innovative approach to successfully treat the majority of patients with severe acute malnutrition, including those who are HIV positive, at home. The approach engages communities in order to identify severely malnourished patients early before they require inpatient care for medical complications. It allows effective treatment – in terms of essential medicines, simple orientation for caregivers, and specially formulated ready-to-use therapeutic foods (RUTF) - to be given on a weekly basis at primary health structures or distribution sites within a day’s walk of people’s homes. The approach is implemented in combination with inpatient care for complicated cases (usually <10% of the caseload, but may be more in high HIV settings) and with supplementary feeding for moderate acute malnutrition.
Third, we provide guidance on programming to support the nutritional and other basic needs of children orphaned and made vulnerable due to HIV/AIDS, which may include provision of an essential support package or a cash transfer system. The essential support package may include health, nutritional education and protection interventions in conjunction with food support provided through the World Food Program.
Finally, UNICEF is working to ensure that HIV is integrated into emergency response strategies for nutrition. The elements include breastfeeding support and counseling in general and for those who come in for continuation of prevention of mother to child transmission services; HIV testing of pregnant women; appropriate and sustainable availability and use of breast-milk substitutes for orphans and other eligible children.
All children are screened for acute malnutrition, and caretakers of malnourished children should be provided with voluntary counseling and testing services for HIV; HIV positive malnourished infants receive therapeutic feeding or supplementary feeding as required, together with appropriate medical care and anti-retroviral treatment (ART) if available; children already on ART should be traced to ensure their treatment is not interrupted. For adults, their nutrition status should be routinely measured and appropriate nutritional care (therapeutic or supplementary feeding) provided, as well as ART if available. It is important that the emergency medical staff familiarize themselves with the dietary implications of ARVs in order to ensure the correct management of the patients.