more diverse and nutrient-rich the diet before starting antiretroviral
treatment (ART), the less severe HIV disease progression is, and the less likely death occurs, researchers report
in the advance online edition of the Journal
of Acquired Immune Deficiency Syndromes. The study involveda
cohort of over 800 people living with HIV (PLHIV) in Uganda.
findings demonstrate the importance of diet quality to the health of PLHIV, an
important contribution considering the World Food Programme (WFP), the World
Health Organization (WHO), UNAIDS and PEPFAR have recommended integration of
food assistance into AIDS care and treatment programmes,” the authors comment.
this secondary analysis of the evaluation of a WFP-supported food-assistance
programme for PLHIV, cross-sectional analysis of baseline food consumption
showed that each addition of a nutrient-rich food group was linked to a 16%
reduction in the likelihood of having a CD4 cell count below or equal to 350 cells/mm3
(adjusted odds ratio [aOR]: 0.84, 95% CI: 0.72-0.97).
those with CD4 cell counts over 350 but not among those under 350 at baseline,
consumption of nutrient-rich food groups was linked to a lower risk of moderate
anaemia (aOR 0.57, 95% CI: 0.34-0.96).
important role of nutrition in health and disease is well understood.
insecurity (limited access for physical, social and/or economic reasons to
nutritious food to meet dietary needs for an active and healthy life) is
recognised as increasing vulnerability to HIV infection, opportunistic
infections, HIV disease progression, increased hospitalisations and death.
research, the authors note, has been focussed on one element of food insecurity
– food access. Little attention, they add, has been on how nutrient-rich foods
and diet quality may be related to HIV disease progression and severity.
many rural populations in sub-Saharan Africa
having a diverse diet adequate to meet basic nutritional needs is a constant
the impact of HIV on health in sub-Saharan Africa
has been devastating, it has also adversely affected food security and diet
quality in households affected by HIV.
the authors chose to look at diet quality and HIV disease progression, moderate
anaemia and death among HIV-infected adults in a resource-poor setting.
primary (WFP) evaluation comprised adults registered between July 2008 and
August 2009 at The AIDS Support Organisation (TASO). A total of 450 participants were each
recruited from two districts: Gulu (getting the food assistance intervention)
and Siroti (serving as a comparison). Participants were interviewed and
followed for an average of 21.6 months.
authors undertook a cross-sectional analysis of the data from the baseline
survey of the evaluation and obtained death data from medical records.
analysis looked at the association between baseline dietary diversity and
immunosuppression (baseline CD4 cell counts under 350 cells/mm3) and
moderate anaemia (haemoglobin under 10g/dl). In addition, the authors used a
prospective cohort to look at the association between baseline dietary
diversity and death. Participant data was collected at the point at which they initiated antiretroviral therapy (at the time this study was conducted treatment was recommended in Uganda when the CD4 cell count fell below 200 cells).
quality was measured using the Individual Dietary Diversity Score (IDDS range
0 to 20), a proxy measure for the nutritional quality of an individual’s diet.
IDDS uses the number of different food groups eaten in the 24 hours before the
interview from the following 12 groups:
roots and tubers
pulses, legumes and nuts
meat and poultry
fish and seafood
milk and milk products
oils and fats
condiments and miscellaneous.
addition to an overall IDDS score, the authors grouped the 12 categories into
three sub-groups with a score for each:
nutrient rich foods (range 0 to 7)
cereals, roots and tubers (range 0 to 2)
oils, fats and condiments (range
0 to 3).
dietary pattern in Uganda
comprises starchy staple foods, high consumption of sugars, fats and oil and
low consumption of foods rich in proteins and micronutrients. In this context,
the authors categorised nutrient-rich foods to include: pulses, legumes and
nuts; vegetables; fruits; meat and poultry; eggs; fish and seafood; and milk
and milk products.
mean IDDS score was 6.3 (standard deviation [SD] 1.7) food groups each day,
with a mean of 2.7 (SD 1.1) nutrient rich food groups each day. Overall, 197 participants (22%) consumed a high level of nutrient-rich foods at baseline
(4 to 7 food groups each day).
a 22-month follow-up period, it was found that the more diverse and nutrient-rich the diet at
baseline, the more protective it was against death. Of the 48 (5.6%) who died,
only six (13%) were among those consuming high levels of nutrient-rich foods.
anaemia has multiple causes, it is acknowledged to be a major consequence of HIV
infection and strongly linked to disease progression and death.
their observations, the authors suggest “nutritional deficiencies possibly
comprise a larger attributable fraction for anemia in individuals with less
advanced HIV disease... when anemia is less affected by HIV infection.”
when HIV is more advanced, the infection plays a greater role in the development
of anaemia, although nutritional deficiencies remain common.
results, the authors note, highlight the importance of ensuring high-quality
diets, especially in resource-poor settings “where the vicious cycle of
HIV/AIDS and food insecurity is the most acute”.
interventions have the potential to limit the ways in which food insecurity and
poor diet compromise the health of HIV-positive people.
have shown the positive effect of food supplementation on adherence and
WFP provides food and nutrition support to more than 1.4 million food-insecure
and malnourished people living with and affected by HIV, the authors write.
While the immediate goal is to manage malnutrition, the long-term goal is to
help get people back into the workforce and maintain future food security.
vouchers or cash offer critical short-term support, while livelihood
interventions and social protection schemes aim to improve food security and
diet quality in the long term, the authors note.
previous findings have shown a link between food security and severity of HIV
disease the authors believe this to be the first study showing the link between
nutrient-rich food consumption and HIV disease severity and death. The strengths
of this study include a large sample size, use of a validated dietary measure and prospective
data on death.
authors conclude: ”our data may help guide the types of food assistance provided
and essential elements of nutrition education and counselling that increase the
likelihood of improving dietary diversity… highlight the need for future
research to determine the most cost-effective approaches to improve diet
quality in both the short- and long-terms.”