Healthy eating

Your existing diet may already meet all your nutritional needs. Having HIV is unlikely to mean that you have to make drastic changes to your diet. However, if you are taking anti-HIV drugs it is important to eat a healthy diet as HIV medication can cause changes to the way the body metabolises, uses and stores fat.

A good diet will consist of a balance of the following items:

Starchy foods Such as bread, cassava, cereals, green banana, millet, maizemeal, potatoes, pasta, rice, and yam. Starchy foods form the basis of your diet and provide carbohydrates for energy, as well as minerals, vitamins and fibre. Try and eat these at every meal and to have four to six portions every day. One portion is equal to one slice of bread, one medium sized potato, one bowl of cereal, a cup of pasta or rice.

Fruit and vegetables Provide vitamins, minerals and fibre. Try and eat five or more portions of fruit or vegetables each day. A portion is equal to one whole piece of fruit, a heaped serving spoon of vegetables, a handful of dried fruit or a small glass of fresh fruit juice. Research has shown that a diet containing lots of fruit and vegetables can help protect against certain cancers and heart disease.

Meat, poultry, fish, eggs, beans, nuts Provide protein, mineral, and vitamins (particularly B12 from meat). Try and eat two or three portions of these foods each day. A portion is equal to two medium eggs, 100g/4oz meat, 150g/6oz piece of fish, or a small tin of baked beans.

Dairy products Such as milk, cheese and yoghurt, to provide vitamins, minerals and especially calcium. Three portions should be eaten a day. A portion is equal to a third of a pint of milk, a small pot of yoghurt, or a match-box sized piece of cheese. If you cannot tolerate milk, then fortified soya milk, dark green leafy vegetables, dried figs, apricots and nuts are all good sources of calcium.

Fat from cooking oils, butter and margarine, meat and other protein-based foods These provide energy, essential fatty acids and fat-soluble vitamins (A,D,E,K). They also provide calcium and phosphate. It is recommended that 30%-35% of your daily calorie intake comes from fats, however you should note that eating too much fat could lead to weight gain, which can increase the chances of developing cardiovascular disease and certain cancers.

If you are having difficulty affording food, or buying food which you are used to eating or need for a special diet, a member of your health care team can put you into contact with someone who can help.

Your diet and lipodystrophy

It has become clear that some anti-HIV drugs can cause a collection of side-effects called lipodystrophy, which is a disturbance in the way the body processes, uses and stores fat. Some people taking HIV drugs have seen their body shape change and blood tests indicate that there are metabolic changes -  increased levels of fats in their blood, possibly increasing their chances of developing heart disease or diabetes.

There is good evidence that diet can help control metabolic changes seen in people taking anti-HIV medication. In particular, it is recommended that people taking anti-HIV drugs who have high cholesterol should cut down on their intake of saturated fats. These come from animal products such as red meat (beef, lamb, oxtail and pork), and dairy products such as butter, cream, whole milk, cheese and full-fat yoghurt, and the vegetable fats palm oil and coconut cream or oil. It is particularly important that people taking anti-HIV drugs, especially if your blood tests indicate that you have high levels of blood fats, eat at least five portions of fruit and vegetables a day. A dietitian can give you advice about this. There is also evidence that cardiovascular exercise, such as running, swimming and cycling, can help reduce levels of blood fats, and resistance training (lifting weights) can help with some of the body changes. For more information see the NAM booklet in this series, Lipodystrophy and the THT booklet, Your shape.

Dietitians

You can obtain advice on nutrition from dietitians. Most HIV clinics have specialist dietitians who can:

• Make sure your diet is fulfilling all your individual nutritional requirements.
• Give you advice about your diet if you are experiencing metabolic changes due to your anti-HIV medication.
• Regularly check your body weight and ensure that the proportion of fat to muscle is appropriate.
• Advise you on any dietary changes you may need to make if you become ill.
• Help you avoid food poisoning.
• Recommend the prescription of sip or drip-feeds and protein or vitamin supplements if these are needed.
• Offer advice on symptom control, such as how to manage changes in taste caused by medication.
• Give therapeutic advice for conditions such as diabetes, obesity, hyperlipidaemia (high levels of fat in the blood) and poor absorption of food.
• Give advice during on your nutritional requirements during pregnancy.
• Look at your food allergies and intolerances.
• Advise you on sports nutrition.
• Provide information and advice on the use of vitamins and minerals and complementary therapies.

Some dietitians may be able to use a variety of tests to assess how much muscle and fat there is in your body. If these tests are done regularly your dietitian may be able to spot changes in weight and body composition before you do. However, you may be the first to notice changes in your weight or body shape, for instance if your clothes become too loose or tight. These may be important times to talk to your dietitian about making changes to your diet or exercise.

Supplements

Many people with HIV decide to supplement their diet with additional vitamins, nutrients, and herbal remedies in the hope of protecting or strengthening their immune system, or maintaining or promoting their general health, weight or body shape. Evidence that they have any effect is controversial and some evidence has emerged that certain supplements can stop HIV drugs working properly.

Most HIV specialists would advise that a healthy, balanced diet is enough.

Research in Africa recently showed that taking a cheap, over-the-counter multivitamin tablet slowed HIV disease progression. Although taking multivitamins are not a replacement for anti-HIV drugs, you may wish to consider discuss with your HIV doctor, pharmacist, or dietitian the value of taking them to delay HIV disease progression.

Megadosages of any nutritional supplement are not, however, recommended.

If you are using B12, which can protect against nerve damage, nuggets that dissolve under the tongue are preferable to tablets that you swallow as they are more readily absorbed. Alternatively you could speak to your HIV doctor or GP about having B12 injections.

Many people use herbal remedies to supplement their diet. It is always important to do this with caution and to tell your doctor what you are taking. Garlic capsules, which are frequently taken because they are believed to protect the heart, stop the protease inhibitor saquinavir (Invirase) working properly and it is thought that they could have a similar effect on other protease inhibitors. St John’s wort, the herbal antidepressant, was also shown to be inappropriate for people on protease inhibitors and non-nucleoside analogues (NNRTIs). The herb was shown to lower levels of the protease inhibitor indiniavir (Crixivan) and researchers concluded that it could have the same effect on all other protease inhibitors and NNRTIs. Test tube studies have also shown that African potato and Sutherlandia, two herbs widely used to treat HIV in Africa, interfere with the body's ability to process protease inhibitors and NNRTIs.

There is also a theoretical risk of an interaction between anti-HIV drugs and aloe vera, borage oil, DHEA, ginko, liquorice, milk thistle and valerian.

It is very important that you tell your doctor, pharmacist and dietitian exactly what supplements you are taking.

High doses of vitamins and minerals

Some people take high doses of certain vitamins and minerals because they believe that they may boost their immune system. Research has shown that large doses of many vitamins may in fact be harmful. Particular toxicities to be aware of include:

• Vitamin A: large amounts can cause liver and bone damage, vomiting and headache. Doses above 9,000 micrograms (for men) or 7,500 micrograms for women, may be harmful. Pregnant women should not take supplements containing vitamin A without consulting their doctor as high intake can be harmful to the developing baby.
• Vitamin C: doses above 1,000mg per day may lead to kidney stones, diarrhoea and hardening of the arteries; special care is needed if you are taking indinavir. Large doses of vitamin C have been shown to reduce concentrations of indinavir in the blood.
• Vitamin E: doses above 800mg per day are associated with adverse effects; special care is needed if you are taking amprenavir, or an anti-coagulant if you have haemophilia.
• Zinc: doses above 75mg per day have been linked to copper deficiency, neutropenia and anaemia.
• Selenium: more than 750 micrograms per day are associated with immune suppression.
• Vitamin B6: more than 2g per day has been associated with nerve damage, but doses as low as 50mg per day have been associated with peripheral neuropathy.
• Calcium: doses greater than 1.5mg are associated with hypercalcaemia (high levels of calcium in the blood).

Alcohol

There is no evidence that moderate alcohol consumption by people with HIV is harmful. Many people find that moderate drinking (one or two units a day) helps relieve stress and anxiety and acts as an appetite stimulant. A unit of alcohol is equal to a half pint of normal strength beer or lager, a glass of wine, a single measure of spirits or a small glass of sherry or port. There is also some evidence that a unit or two of alcohol drunk daily can help protect against heart disease and diabetes. It is recommended that men drink no more than three or four units of alcohol a day and women a maximum of two or three units a day.

However, heavy drinking can affect your immune system and may slow down your ability to recover from infections. Heavy drinking is also linked to hepatitis and liver damage. It is particularly important that people with HIV take care of their liver, not least because the liver plays an important part in metabolising anti-HIV medicines. Heavy drinking may also lead to vomiting. If you vomit within an hour of taking your medicine, you should retake the dose. Heavy drinking means ten or more units of alcohol a day. Binge drinking can also be harmful to general health, so don’t drink all your weekly safe allowance in one day.

People who are co-infected with either hepatitis B or C should be aware that even minimal alcohol intake is not advisable.

Water

It is important to stay properly hydrated to ensure that the body has enough fluid to function properly. Everybody is recommended to drink about two litres of water a day. It is especially important to drink plenty of fluids if you are taking some anti-HIV drugs to help the body process them properly and avoid side-effects.

If you have a fever, or have diarrhoea, then it is important to drink extra fluids. Similarly, if you are exercising it is important to stay properly hydrated and increase your water or sports drink intake.

You can replace some of your daily fluid intake with fruit juices or squashes diluted with still or fizzy water, however you should be aware that alcohol dehydrates the body as does coffee, cola and to a lesser extent, tea.

Food and water safety

If you are HIV-positive, particularly if your CD4 count is below 200, you may be more vulnerable to food poisoning. The risks can be reduced by taking care during the preparation, cooking and storage of food.

The following tips might be useful:

• Avoid raw meat, raw fish, sushi, raw eggs, undercooked chicken, poultry or pork.
• Avoid unpasteurised or blue cheese (such as Brie or Stilton), milk and yogurt.
• Avoid live yogurt and probiotic drinks and supplements.
• Make sure that food is thoroughly reheated if it has already been cooked.
• Avoid food that is mouldy or has passed its sell-by date.
• Wash fruit and vegetables thoroughly.
• Make sure that uncooked food is kept separate from cooked food.
• Cooked stews should be kept in the fridge and eaten within two days. Portions should be frozen if you wish to keep for longer than two days.

Drinking water safety

If your CD4 count is below 200, then you may wish to boil your drinking water. This will reduce the chances of picking up waterborne infections such as cryptosporidiosis, which very rarely finds its way into the UK’s drinking water. Once boiled and cooled the water can be left in a bottle or covered in a jug in the fridge for up to 24 hours. It can be used for drinking, preparing food and brushing teeth.

Unfortunately, it is not possible to guarantee that bought mineral and spa waters are free from waterborne infections. Much bottled water comes from exactly the same source as tap water and even water from mountain springs may be contaminated.

Water filters

To protect against cryptosporidiosis and other waterborne infections, a water filter needs to be able to remove all particles above 1 micron in size.

Unfortunately jug filters are not suitable for this job and you will need to have a filter fixed to your water supply to avoid boiling tap water. The filter will need changing at regular intervals as it may start to harbour potentially harmful bacteria.