Clin Infect Dis. 2009 Oct 1;49(7):1096-102.
HIV/AIDS, undernutrition, and food
insecurity.
Ivers LC, Cullen KA, Freedberg KA, Block S, Coates J, Webb P.
Source
Partners In Health, Boston, MA, USA. livers@pih.org
Abstract
Despite tremendous advances in care for human immunodeficiency virus (HIV) infection and
increased funding for treatment, morbidity and mortality due to HIV/AIDS in developing
countries remains unacceptably high. A major contributing factor is that >800 million people
remain chronically undernourished globally, and the HIV epidemic largely overlaps with
populations already experiencing low diet quality and quantity. Here, we present an updated
review of the relationship between HIV infection, nutritional deficiencies, and food insecurity
and consider efforts to interrupt this cycle at a programmatic level. As HIV infection
progresses, it causes a catabolic state and increased susceptibility to other infections, which
are compounded by a lack of caloric and other nutrient intake, leading to progressive
worsening of malnutrition. Despite calls from national and international organizations to
integrate HIV and nutritional programs, data are lacking on how such programs can be
effectively implemented in resource-poor settings, on the optimum content and duration of
nutritional support, and on ideal target recipients.
Comment on

Clin Infect Dis. 2009 Oct 1;49(7):1061-8.
Supplemental Content
BMC Public Health. 2008 Jul 2;8:226.
Prevalence and pattern of HIV-related
malnutrition among women in sub-Saharan
Africa: a meta-analysis of demographic
health surveys.
Uthman OA.
Source
Center for Evidence-Based Global Health, Save the Youth Initiative, Nigeria.
uthlekan@cebglobalhealth.org
Abstract
BACKGROUND:
The world's highest HIV infection rates are found in Sub-Saharan Africa (SSA), where adult
prevalence in most countries exceeds 25%. Food shortages and malnutrition have combined
with HIV/AIDS to bring some countries to the brink of crisis. The aim of this study was to
describe prevalence of malnutrition among HIV-infected women and variations across
socioeconomic status using data from 11 countries in SSA.
METHODS:
This study uses meta-analytic procedures to synthesize the results of most recent data sets
available from Demographic and Health Surveys of 11 countries in SSA. Pooled prevalence
estimates and 95% confidence intervals were calculated using random-and fixed-effects
models. Subgroup and leave-one-country-out sensitivity analyses were also carried out.
RESULTS:
Pooling the prevalence estimates of HIV-related malnutrition yielded an overall prevalence of
10.3% (95% CI 7.4% to 14.1%) with no statistically significant heterogeneity (I2 = 0.0%, p =
.903). The prevalence estimates decreased with increasing wealth index and education
attainment. The pooled prevalence of HIV-related malnutrition was higher among women
residing in rural areas than among women residing in urban areas; and lower among women
that were professionally employed than unemployed or women in agricultural or manual
work.
CONCLUSION:
Prevalence of HIV-related malnutrition among women varies by wealth status, education
attainment, occupation, and type of residence (rural/urban). The observed socioeconomic
disparities can help provide more information about population subgroups in particular need
and high risk groups, which may in turn lead to the development and implementation of more
effective intervention programs.
Supplemental Content
Clin Infect Dis. 2008 Mar 15;46(6):946-9.
Nutritional status of persons with HIV
infection, persons with HIV infection and
tuberculosis, and HIV-negative individuals
from southern India.
Swaminathan S, Padmapriyadarsini C, Sukumar B, Iliayas S, Kumar SR, Triveni C, Gomathy
P, Thomas B, Mathew M, Narayanan PR.
Source
Tuberculosis Research Centre, Chetpet, Chennai, India. doctorsoumya@yahoo.com
Abstract
We compared the nutritional status of individuals with human immunodeficiency virus (HIV)
infection alone, individuals with HIV infection and tuberculosis (after completion of
antituberculosis treatment), and HIV-negative individuals and found that malnutrition,
anemia, and hypoalbuminemia were most pronounced among HIV-positive patients with
tuberculosis. Weight loss was associated with loss of fat in female patients and with loss of
body cell mass in male patients.
Supplemental Content
Scand J Public Health Suppl. 2007 Aug;69:96-106.
What's new? Investigating risk factors for
severe childhood malnutrition in a high
HIV prevalence South African setting.
Saloojee H, De Maayer T, Garenne ML, Kahn K.
Source
Department of Paediatrics and Child Health, University of Witwatersrand, Johannesburg,
South Africa. Haroon.Saloojee@wits.ac.za
Abstract
AIM:
To identify risk factors for severe childhood malnutrition in a rural South African district with
a high HIV/AIDS prevalence.
DESIGN:
Case-control study.
SETTING:
Bushbuckridge District, Limpopo Province, South Africa.
PARTICIPANTS:
100 children with severe malnutrition (marasmus, kwashiorkor, and marasmic kwashiorkor)
were compared with 200 better nourished (>-2 SD weight-for-age) controls, matched by age
and village of residence. Bivariate and multivariate analyses were conducted on a variety of
biological and social risk factors.
RESULTS:
HIV status was known only for a minority of cases (39%), of whom 87% were HIV positive,
while 45% of controls were stunted. In multivariate analysis, risk factors for severe
malnutrition included suspicion of HIV in the family (parents or children) (OR 217.7, 95% CI
22.7-2091.3), poor weaning practices (OR 3.0, 95% CI 2.0-4.6), parental death (OR 38.0,
95% CI 3.8-385.3), male sex (OR 2.7, 95% CI 1.2-6.0), and higher birth order (third child or
higher) (OR 2.3, 95% CI 1.0-5.1). Protective factors included a diverse food intake (OR 0.53,
95% CI 0.41-0.67) and receipt of a state child support grant (OR 0.44, 95% CI 0.20-0.97). A
borderline association existed for family wealth (OR 0.9 per unit, 95% CI 0.83-1.0), father
smoking marijuana (OR 3.9, 95% CI 1.1-14.5), and history of a pulmonary tuberculosis
contact (OR 3.2, 95% CI 0.9-11.0).
CONCLUSIONS:
Despite the increasing contribution of HIV to the development of severe malnutrition,
traditional risk factors such as poor nutrition, parental disadvantage and illness, poverty, and
social inequity remain important contributors to the prevalence of severe malnutrition.
Interventions aiming to prevent and reduce severe childhood malnutrition in high HIV
prevalence settings need to encompass the various dimensions of the disease: nutritional,
economic, and social, and address the prevention and treatment of HIV/AIDS.
Comment in

Scand J Public Health Suppl. 2007 Aug;69:128-9.
Supplemental Content
J Infect Dev Ctries. 2010 Nov 24;4(11):745-9.
Nutritional status of HIV-positive
individuals on free HAART treatment in a
developing nation.
Obi SN, Ifebunandu NA, Onyebuchi AK.
Source
University of Nigeria Teaching Hospital Enugu, Nigeria. samnobis@yahoo.co.uk
Abstract
INTRODUCTION:
HIV positive individuals are prone to malnutrition due to inadequate dietary intake.
Additionally, in low-income countries, including Nigeria, stigmatization and discrimination
result in a lack of support for HIV-positive individuals ultimately contributing to even further
reduced food availability and inadequate dietary intake. This study aimed to determine the
nutrirional status of HIV-positive individuals on free, highly active antiretroviral therapy
(HAART) in Abakaliki, southeast Nigeria.
METHODOLOGY:
Subjective global assessment (SGA) technique was used to survey the nutritional status of 120
HIV-positive individuals and a control group over a one-year period.
RESULTS:
All the HIV-positive individuals and their control group were physically active, with a third of
them belonging to the lower socioeconomic status. There were significantly more
malnourished individuals among the HIV-positive group than in the control group (P < 0.05).
CONCLUSION:
Malnutrition is common among HIV-positive patients in southeast Nigeria.
Supplemental Content
AIDS. 1997 Apr;11(5):613-20.
Association between serum vitamin A and E
levels and HIV-1 disease progression.
Tang AM, Graham NM, Semba RD, Saah AJ.
Source
Department of Epidemiology, Johns Hopkins University School of Medicine, Baltimore,
Maryland, USA.
Abstract
OBJECTIVE:
To examine the associations between serum vitamin A and E levels and risk of progression to
three key outcomes in HIV-1 infection: first AIDS diagnosis, CD4+ cell decline to < 200 cells
x 10(6)/l, and mortality.
DESIGN:
Non-concurrent prospective study.
METHODS:
Serum levels of vitamins A and E were measured at the enrollment visit of 311 HIVseroprevalent homo-/bisexual men participating in the Baltimore/ Washington DC site of the
Multicenter AIDS Cohort Study. Cox proportional hazards models were used to estimate the
relative hazard of progression to each outcome over the subsequent 9 years, adjusting for
several independent covariates.
RESULTS:
Men in the highest quartile of serum vitamin E levels (> or = 23.5 mumol/l) showed a 34%
decrease in risk of progression to AIDS compared with those in the lowest quartile [relative
hazard (RH), 0.66; 95% confidence interval (CI), 0.41-1.06)]. This effect was statistically
significant when comparing the highest quartile of serum vitamin E to the remainder of the
cohort (RH, 0.67; 95% CI, 0.45-0.98). Associations between serum vitamin A levels and risk
of progression to AIDS were less clear, but vitamin A levels were uniformly in the normal to
high range (median = 2.44 mumol/l). Similar trends were observed for each vitamin with
mortality as the outcome, but neither vitamin was associated with CD4+ cell decline to < 200
cells x 10(6)/l. Men who reported current use of multivitamin or single vitamin E supplements
had significantly higher serum tocopherol levels than those who were not taking supplements
(P = 0.0001). Serum retinol levels were unrelated to intake of multivitamin or single vitamin
A supplements.
CONCLUSIONS:
These data suggest that high serum levels of vitamin E may be associated with slower HIV-1
disease progression, but no relationship was observed between retinol levels and disease
progression in this vitamin A-replete population.
Supplemental Content
J Nutr. 1997 Feb;127(2):345-51.
Low serum vitamin B-12 concentrations are
associated with faster human
immunodeficiency virus type 1 (HIV-1)
disease progression.
Tang AM, Graham NM, Chandra RK, Saah AJ.
Source
Department of Epidemiology, Johns Hopkins School of Hygiene and Public Health,
Baltimore, MD 21205, USA.
Abstract
We conducted a nonconcurrent prospective cohort study to examine associations between
serum concentrations of vitamin B-6, vitamin B-12 and folate and the risk of progression to
first acquired immunodeficiency syndrome (AIDS) diagnosis and CD4+ cell decline to < 2 x
10(8) cells/L. The study population was drawn from a cohort of homosexual and bisexual men
in the Baltimore-Washington, DC, area. Eligible subjects were human immunodeficiency
virus type 1 (HIV-1)-seropositive at study entry and had serum available in the serum
repository from their 1984 baseline study visit. Serum micronutrient levels were assessed in
310 subjects. The follow-up period (April 1984 through December 1993) was approximately
9 y. In Kaplan-Meier analyses, participants with low serum vitamin B-12 concentrations (<
120 pmol/L) had significantly shorter AIDS-free time than those with adequate vitamin B-12
concentrations (median AIDS-free time = 4 vs. 8 y, respectively, P = 0.004). This effect
persisted in Cox proportional hazards models after adjusting for HIV-1-related symptoms,
CD4+ cell count, age, serum albumin, use of antiretroviral therapy before AIDS, frequency of
alcohol consumption and serum folate concentration [relative hazard (RH) = 1.89, 95%
confidence interval (CI) = 1.15-3.10). To further explore the temporal relation between low
serum vitamin B-12 concentrations and disease progression, additional analyses were
performed excluding subjects with more advanced disease at baseline. In these analyses, the
increase in risk of progression to AIDS for those with low serum vitamin B-12 concentrations
remained significant (RH = 2.21, 95% CI = 1.13-4.34), providing further evidence that low
vitamin B-12 concentrations preceded disease progression. In contrast, low serum
concentrations of vitamin B-6 and folate were not associated with either progression to AIDS
or decline in CD4+ lymphocyte count. Intervention studies are needed to determine whether
correction of low serum vitamin B-12 concentrations in early HIV-1 infection will influence
the natural history of disease progression.
Supplemental Content
Ann Afr Med. 2010 Oct-Dec;9(4):235-9.
Serum levels of antioxidant vitamins and
mineral elements of human
immunodeficiency virus positive subjects in
Sokoto, Nigeria.
Bilbis LS, Idowu DB, Saidu Y, Lawal M, Njoku CH.
Source
Department of Biochemistry, Usmanu Danfodiyo University, Sokoto, Nigeria.
Abstract
BACKGROUND:
Undernourishment and micronutrient deficiencies exacerbate immunosuppression, oxidative
stress, acceleration of human immunodeficiency virus (HIV) replication and CD4 T-cell
depletion in HIV-infected individuals.
MATERIALS AND METHODS:
The current work reports the serum levels of antioxidant vitamins (vitamins A, C and E) and
minerals (Zn, Fe, Cu) in 90 HIV positive subjects attending the Usmanu Danfodiyo
University Teaching Hospital (UDUTH), Sokoto, Nigeria. The serum levels of the
micronutrients were correlated with the CD4 count of the subjects.
RESULTS:
The results showed that the HIV positive subjects have significantly lower (P < 0.05) levels of
vitamins A, C and E. Also, serum Zn, Fe, Cu and CD4 count were also significantly (P <
0.05) lower compared with the HIV negative subjects. Micronutrient deficiencies were more
pronounced in HIV positive subjects with CD4 counts less than 200 cell/μl. The results based
on age and sex showed no significant (P > 0.05) difference. Vitamins A, E and C and Zn and
Fe showed positive correlation with CD4 count of the HIV positive subjects.
CONCLUSION:
The results suggest that the HIV subjects in the study area have lowered serum levels of
antioxidant micronutrients and that the levels decrease with increase in the severity of the
infection. These may increase the chances of the symptomatic and asymptomatic subjects
progressing into full-blown Acquired Immunodeficiency Syndrome.
PMID:
20935424
[PubMed - indexed for MEDLINE]
Free full text
Supplemental Content
Am J Epidemiol. 1996 Jun 15;143(12):1244-56.
Effects of micronutrient intake on survival
in human immunodeficiency virus type 1
infection.
Tang AM, Graham NM, Saah AJ.
Source
Department of Epidemiology, Johns Hopkins University, School of Hygiene and Public
Health, Baltimore, MD, USA.
Abstract
The authors examined the relation between dietary and supplemental micronutrient intake and
subsequent mortality among 281 human immunodeficiency type 1 (HIV-1)-infected
participants at the Baltimore, Maryland/Washington, DC, site of the Multicenter Acquired
Immunodeficiency Syndrome Cohort Study. Subjects completed a semiquantitative food
frequency questionnaire at their baseline visit in 1984. Levels of daily micronutrient intake
were examined in relation to subsequent mortality over the 8-year follow-up period by using
multivariate Cox models, adjusting for age, symptoms, CD4+ count, energy intake, and
treatment. The highest quartile of intake for each B-group vitamin was independently
associated with improved survival: B1 (relative hazard (RH) = 0.60, 95% confidence interval
(CI) 0.38-0.95), B2 (RH = 0.59, 95% CI 0.38-0.93), B6 (RH = 0.45, 95% CI 0.28-0.73), and
niacin (RH = 0.57, 95% CI 0.36-0.91). In a final model, the third quartile of beta-carotene
intake (RH = 0.60, 95% CI 0.37-0.98) was associated with improved survival, while
increasing intakes of zinc were associated with poorer survival. Intakes of B6 supplements at
more than twice the recommended dietary allowance were associated with improved survival
(RH = 0.60, 95% CI 0.39-0.93), while intakes of B1 and B2 supplements at levels greater than
five times the recommended dietary allowance were associated with improved survival (B1:
RH = 0.61, 95% CI 0.38-0.98; B2:RH = 0.60, 95% CI 0.37-0.97). Any intake of zinc
supplements, however, was associated with poorer survival (RH = 1.49, 95% CI 1.02-2.18).
These data support the performance of clinical trials to assess the effects of B-group vitamin
supplements on HIV-1-related survival. Further studies are needed to determine the optimal
level of zinc intake in HIV-1-infected individuals.
Supplemental Content