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HIV & AIDS

HIV & AIDS. Lisa Bullard Shannon Rohall. Outline. Background Information/MNT Epidemiology Pathophysiology Diagnosis Clinical Manifestations Treatment Research supporting MNT Terry’s Story Nutrition Care Process ADIM/E. Epidemiology- U.S.A.

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HIV & AIDS

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  1. HIV & AIDS Lisa Bullard Shannon Rohall

  2. Outline • Background Information/MNT • Epidemiology • Pathophysiology • Diagnosis • Clinical Manifestations • Treatment • Research supporting MNT • Terry’s Story • Nutrition Care Process • ADIM/E

  3. Epidemiology- U.S.A. • Prevalence: roughly 1 million with HIV & AIDS Race/ethnicity of persons living with HIV, 2003 http://www.cdc.gov/hiv/topics/surveillance/united_states.htm

  4. Epidemiology- U.S.A. • Incidence: • 40,000 new cases each year • Majority of new infections affect: • Minorities • Women • Youth w/ little access to healthcare (Center for Disease Control and Prevention, 2005) Race/ethnicity of persons with a new HIV diagnosis in 2006 http://www.cdc.gov/hiv/topics/surveillance/united_states.htm

  5. Background Information- Etiology • What is HIV? • Human Immunodeficiency Virus is a retrovirus. • Targets GI, organ, and immune cells (specifically CD4 cells, “T helper”) • What is AIDS? • Acquired Immunodeficiency Syndrome is “an immune dysfunction characterized by the destruction of immune cells, leaving the body open to infection” (Nelms, et al. 2008).

  6. Pathophysiology • Figure 26.1 HIV Lifecycle (Nelms et al. 2008)

  7. Pathophysiology • ↑ viral load  ↓ CD4 cells  strong relationship to progression to diagnosis of AIDS • ↓ CD4 cells  ↑ opportunistic infection  ↓ nutrition status and ↑ mortality http://hivtreatmentispower.com/images/immune-system-hiv.jpg

  8. Pathophysiology • When GI cells infected (part of immune defense), ↑ risk of malabsorption • Contributes to wasting AIDS-related wasting syndrome http://student.bmj.com/issues/02/12/education/images/view_1.jpg

  9. Pathophysiology • Breakdown of protein stores • Protein turnover rate higher throughout infection • Dysregulation of inflammation response  changes in hormone/nutrient metabolism  ↑ risk of chronic ds

  10. Micronutrient Changes • Elevated levels of: • Folate* • Niacin • Carnitine • Lower levels of: • Selenium* • Zinc* • Magnesium • Calcium • Iron* • Manganese • Copper* • Carotene • Choline • Glutathione • Vit A* • Vit B6* • Vit B12* (neurological changes, bone marrow toxicity, and accelerated progression of HIV) • Vit E (oxidative stress) * Closely tied to immune fx (Nelms, et al. 2008)

  11. Diagnostic Criteria CDC Clinical and Immune Cell Categories of HIV Infection

  12. Diagnostic Criteria Table 26.2 WHO Clinical and Immune Cell Categories of HIV/AIDS Infection Broken down into classifications set forth by WHO: presence of opportunistic infection and unintentional wt loss (Nelms et al., 2008)

  13. Clinical Manifestations • Neurological disorders common w/ HIV and treatment • Loss of ability to perform ADL’s • Pulmonary disorders may result in inability to maintain adequate food intake • HIV infected pt at higher risk of cardiac ds • Hepatic ds • Anemias common in symptomatic phases • Renal failure • Oral lesions and food intake Oral Candidiasis (Thrush) www.research.bidmc.harvard.edu/.../38_240.jpg

  14. Treatments • Antiretroviral medication • Modulation of altered • hormonal environment • Prevention/treatment • for opportunistic • events • Maintenance and • restoration for • nutritional status • (Nelms et al. 2008) http://cache.daylife.com/imageserve/04MS19v34822G/610x.jpg Multidisciplinary approach!!

  15. Treatment • While effective, med cocktail makes pt very ill • Diarrhea • N/V • Appetite loss • Abdominal pain • Taste change • Lipid alterations • Glucose intolerance • Lipodystrophy  • Adherence to medications 20-50% due to side effects of drugs • Requires 95% adherence for effectiveness (Nelms et al. 2008) http://www.nature.com/nrd/journal/v2/n8/thumbs/nrd1151-f2.jpg

  16. Medical Nutrition Therapy • MNT goal: support immune fx • Kcal requirements: ↑ 10%-15% (Grunfeld, et al., 1992) • ↑ REE vs healthy controls (E.A.L. summary- Grade II) • Protein Requirements- Adequate intake to: • maintain nitrogen balance • maintain normal albumin/prealbumin • prevent wasting • Counteract some meds ↓ muscular protein synthesis • General recommendation: 1.6-1.8 g/kg of current body weight (McDermott, et al., 2003) if wasted.

  17. MNT, continued • Fat Requirements • Amount and types based on: • Energy needs • Cardiovascular risk (high risk pt.) • Inflammatory condition (oral thrush) • Fiber • Similar to healthy controls: • May improve glu tolerance • Reduce potential cardiovascular risk and altered fat deposition (ie, lipodystrophy) http://diabetestotalcontrol.com/images/fats_visible_in_combi.jpg

  18. Medical Nutrition Therapy Weight Loss: • Implications: • - Risk of developing AIDS • Viral load • Cause: • - Malabsorption • - Oral symptoms/ • trouble swallowing • - Certain medications • - Inflammation • - Lipodystrophy

  19. Pt: Terry Long • 32 y/o African American male • Chief Complaint: • Feels exhausted all the time • Sore mouth and throat • Lost wt • Medical Diagnosis: HIV 4 yrs ago • Not treated previously • Re-diagnosed with AIDS Clinical Category C2, with oral thrush • SES: • Bachelors degree, employed as dialysis nurse • Moved in w/ parents d/t unemployment and inability to care for self • Purchasing/preparation of meals done by parents and pt http://tacomaconfidential.typepad.com/.a/6a00d8341d651053ef0105356d2291970b-120wi

  20. Assessment: Lab Values

  21. Assessment: Physical Exam • Thin appearance • HR: 92 bpm • BP: 120/84 mm Hg • Skin warm and dry w/ flaky patches • May indicate malabsorption • Rhonchi in lower left lung • Rattling sounds caused my mucosal secretions • May indicate pneumonia • Hyperactive bowel sounds • May indicate bowel necrosis or infectious enteritis • http://www.nlm.nih.gov/medlineplus/ency/article/003137.htm http://www.thaipedlung.org/images/shortcase/board36_1.gif

  22. Assessment: Anthropometrics • BMI = 20 (19.9) • Below 20 associated w/ ↑ risk for mortality (Nelms et al. 2008) • IBW = 184 lb ± 10% = 166-202 lb • %IBW: 82% = mildly depleted energy stores • UBW = 160-165 lb • %UBW = 93% • MAC: 25.4 cm • Normal: ~ 37cm • % body fat: 12.5% • TSF: 0.7cm 23 %ile • Normal: 1.07 cm • cAMA (midarm muscle area) = 32.84 cm² • Interpretation: <5th percentile: wasted

  23. Assessment: Diet-Drug Interactions • Indinavir: antiviral protease inhibitor • No grapefruit / grapefruit juice • Adequate hydration needed • Taste changes, N/V, regurgitation, abdominal pain, diarrhea • ↑ glucose, ↑ bilirubin, ↑ amylase • Headaches, ascites, kidney stones, insomnia, back or flank pain, weakness, rare diabetes • Stavudine: antiviral • Anorexia, ↓ wt • Stomatitis, N/V, abdominal pain, diarrhea • Peripheral neuropathy, chills/fever, headache, weakness, muscle pain, dementia, insomnia, rash, pancreatitis • Limit alcohol consumption • ↑ bilirubin, ↑ amylase, ↑ lipase, anemia, ↓ platelets, ↓ neutrophils

  24. Assessment: Diet-Drug Interactions • Didanosine: antiviral • Anorexia, ↓ wt • Dry mouth, stomatitis, ↓ taste acuity, dyspepsia, N/V, pain, diarrhea, constipation, flatulence • Avoid alcohol • Pancreatitis, peripheral neuropathy, headache, weakness, insomnia, rash, arthritis, pain, dizziness, congestion, chills/fever, blurred vision, cough, confusion, anxiety, edema, ↑ BP, seizures • ↑ bilirubin, ↑ alk phos, ↑ uric acid, ↑ amylase, ↑ lipase, ↑ TG, ↑ CPK, ↓ K • Fluconazole: antifungal (oral candidasis) • Taste changes, dry mouth, N/V, abdominal pain, diarrhea • Hypoglycemia, headache, rash, tremor, ↑ sweating, hepatotoxicity • ↑ alk phos, ↑ bilirubin

  25. Assessment: Herb-Drug Interactions • Echinacea: may inhibit metabolism of indinavir (Cyt P-450) • St. John’s Wort: contraindicated with use of protease inhibitors (indinavir) (Nelms et al. 2008) http://graphics8.nytimes.com/images/2007/08/01/health/adam/19306.jpg http://www.global-b2b-network.com/direct/dbimage/50070102/Echinacea_Root_Powder_Extract.jpg

  26. Assessment: Diet Hx Usual Intake: • Breakfast/lunch • cold cereal 1-2 C w/ ½ C whole milk • Supper • Meat: pork chops or other meat, except beef • Mashed potatoes, rice, or pasta, 1 C w/ tea or soda • Snacks: • Pizza, candy bar, or cookies w/ tea or soda • 1-2 beers or glasses wine several x per week Food allergies: • Little milk at a time Dislikes: • beef, coffee, and vegetables (except salad)

  27. Assessment: Intake 24 hr recall: • Sips of applejuice • Pudding, 1 C • Rice and gravy, 1 C • Iced tea w/ sugar • Sips throughout day • Diet Analysis: • 672 kcals • Fat: 16% • Protein: 7% • Fiber: 4 g • Fluids: inadequate Calories needed with H-B equation: 3099 kcals (AF: 1.2, IF: 1.5)

  28. Diagnosis • Inadequate oral food / beverage intake (NI-2.1) related to oral thrush and reduced appetite as evidenced by 9-14 lb wt loss, TSF in 23%ile, and 24-hr recall.

  29. Intervention • Modify distribution, type, or amount of food and nutrients within meals or at specified time (ND-1). • ↑ calorie, ↑ protein: ~3100 kcals • Avoid grapefruit / grapefruit juice • Supplemental feeding: Ensure • Multivitamin

  30. Intervention • Nutrition education and counseling (Fitch, et al., 2006) • Weight maintenance • Drug-nutrient interactions • Other nutritional conditions: hyperlipidemia, family hx of HTN & CAD • Herbs: • Ginseng: ↑ BP • Vit C: RDA in comparison to dose currently taking • Milk thistle: laxative effect, upset stomach, diarrhea, bloating – pros & cons

  31. Intervention • Action goals • Eat two more snacks each day • Drink one Ensure/day • Increase fluids • Outcome goals • Short term: • stop wt loss by ↑ caloric intake • Slowly introduce more food as thrush is treated • Increase fluid consumption • Long term: • wt gain back to UBW • ↑ fruit, veg, dairy (lactose reduced), protein, and fiber intake • ↑ intake of unsat fat and ↓ sat fat • Protein store maintenance • Regular physical activity (aerobic and resistance)

  32. Monitor / Evaluate • Check in w/ pt daily to monitor tolerance and intake • Offer services for post – DC. • Possible referral to social worker for resources.

  33. References • CDC: HIV and AIDS in the United States: A Picture of Today’s Epidemic. 2005. http://www.cdc.gov/hiv/topics/surveillance/united_states.htm. Accessed April 8, 2009. • Nelms, et al. “Nutrition Therapy and Pathophysiology”. Belmont: Thompson Corp. 2008. • Cunningham-Rundles, McNeely, and Moon. 2005. • Fitch KV, Anderson EJ, Hubbard JL, Carpenter SJ, Waddell WR, Caliendo AM, Grinspoon SK. “Effects of a lifestyle modification program in HIV-infected individuals with the metabolic syndrome”. AIDS. 2006; 20: 1843-1850 • C Grunfeld, M Pang, L Shimizu, JK Shigenaga, P Jensen, and KR Feingold. “Resting energy expenditure, caloric intake, and short-term weight change in human immunodeficiency virus infection and the acquired immunodeficiency syndrome”. Am. J. Clinical Nutrition, Feb 1992; 55: 455 – 460. • McDermott AY, et al.: Nutrition treatment for HIV wasting: a prescription for food as medicine, Nutr Clin Pract 18:86, 2003.

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