World Health Organization Consultation on Nutrition and HIV/AIDS in Africa: Participant's Statement

Durban, South Africa, 10–13 April 2005

Participants’ Statement
HIV/AIDS is affecting more people in eastern and southern Africa than our fragile health systems can treat, demoralizing more children than our educational systems can inspire, creating more orphans than communities can care for, wasting families and threatening our food systems. The HIV/AIDS epidemic is increasingly driven by and contributes to factors that also create malnutrition -in particular, poverty, emergencies and inequalities.
In urgent response to this situation, we call for the integration of nutrition into the essential package of care, treatment and support for people living with HIV/AIDS and efforts to prevent infection.

We recognize that,
1. Far reaching steps need to be taken to reverse the current trends in malnutrition, HIV-infection and food insecurity in most countries in the region, in order to achieve the Millennium Development Goals.
2. Adequate nutrition cannot cure HIV infection but it is essential to maintain the immune system and physical activity, and to achieve optimal quality of life.
3. Adequate nutrition is required to optimize the benefits of antiretroviral drugs (ARVs), which are essential to prolong the lives of HIV-infected people and prevent HIV transmission from mother-to-child.
4. There is a proliferation in the marketplace of untested diets and dietary therapies, which exploit fears, raise false hopes and further impoverish those infected and affected by HIV and AIDS.
5. Exceptional measures are needed to ensure the health and well-being of all children affected and made vulnerable by HIV/AIDS. Young girls are especially at risk.
6. Knowledge of HIV status is important to inform reproductive health and child feeding choices.


Conclusions
This consultation reviewed the scientific evidence and discussed the programmatic experience on nutrition and HIV/AIDS and has come to the following conclusions:

Macronutrients
* HIV-infected adults and children have increased energy needs compared with uninfected adults and children. Energy needs increase by 10 percent in asymptomatic HIV-infected adults and children. Energy needs for adults suffering from more advanced disease are increased by 20 to 30%. In HIV-infected children experiencing weight loss, energy needs are increased by 50 to 100%.
* There is no evidence for an increased need for protein intake of people infected by HIV/AIDS over and above that required in a balanced diet to satisfy energy needs (12 to 15% of total energy intake).
* Loss of appetite and poor dietary intake are important causes of weight loss associated with HIV infection. Effective ways of improving dietary intakes need development and documentation.


Micronutrients
* Micronutrient deficiencies are frequently present in HIV-infected adults and children.
* Micronutrient intakes at daily recommended levels need to be assured in HIV-infected adults and children through consumption of diversified diets, fortified foods, and micronutrient supplementation as needed.
* WHO recommendations on vitamin A, zinc, iron, folate and multiple micronutrient supplements remain the same.
* Studies have shown that some micronutrient supplements may prevent HIV disease progression and adverse pregnancy outcomes. Additional research is urgently required.

Pregnancy and Lactation
* Pregnancy and lactation do not hasten the progression of HIV infection to AIDS.
* Optimal nutrition of HIV-infected mothers during pregnancy and lactation increases weight gain, and improves pregnancy and birth outcomes.
* HIV-infected pregnant women gain less weight and experience more frequent micronutrient deficiencies.

Growth
* HIV infection impairs the growth of children early in life. Growth faltering is often observed even before the onset of symptomatic HIV infection. Poor growth is associated with increased risk of mortality.
* Viral load, chronic diarrhoea and other opportunistic infections impair growth in HIV-infected children. The growth and survival of HIV-infected children is improved by prophylactic cotrimoxazole, ARV therapy and the early prevention and treatment of opportunistic infections. * Improved dietary intake is essential to enable children to regain lost weight after opportunistic infection.

Infant and Young Child Feeding
* For HIV-uninfected mothers and mothers who do not know their HIV status, exclusive breastfeeding for six months is the ideal practice because of its benefits for improved growth, development and reduced childhood infections. Safe and appropriate complementary feeding and continued breastfeeding for 24 months and beyond is recommended.
* The risk of HIV transmission through breastmilk is constant throughout the period of breastfeeding and is greatest among women newly infected or with advanced disease.
Studies further support that exclusive breastfeeding is associated with less HIV transmission than mixed breastfeeding.
* WHO/UNICEF recommend that HIV-infected mothers avoid breastfeeding when replacement feeding is acceptable, feasible, affordable, sustainable and safe. However these conditions are not easily met for the majority of mothers in the region.
* Evidence shows that safer infant feeding can be achieved with adequate support, however health systems and communities are not providing this support to make infant feeding safer.
* Early breastfeeding cessation is recommended for HIV-infected mothers and their infants. *The age for breastfeeding cessation depends on the individual circumstances of mothers and their infants. The consequences of this on transmission, mortality, growth and development need to be urgently studied. There is an immediate need to evaluate suitable ways of meeting nutritional needs of infants and young children who are no longer breastfed.

Nutrition and ARV interaction
* The life-saving benefits of ARVs are clearly recognized. To achieve the full benefits of ARVs, adequate dietary intake is essential.
* Dietary and nutritional assessment is an essential part of comprehensive HIV care both before and during ARV treatment.
* Long term use of ARVs can be associated with metabolic complications (cardiovascular disease, diabetes and bone related problems). The value of ARV therapy far outweighs the risks and the metabolic complications need to be adequately managed. The challenge is how best to apply that extensive clinical experience in managing these types of metabolic disorders in HIV infected adults and children in Africa.
* Interactions between nutrition and ARVs in chronically malnourished populations, severely malnourished children, and pregnant and lactating women need to be investigated.
* The effects of traditional remedies and dietary supplements on the safety and efficacy of ARV drugs need to be evaluated.

Recommendations for Action
Based on these conclusions all concerned parties are urged to make nutrition an integral part of their response to the challenges of the HIV/AIDS pandemic and the following recommendations are made for immediate implementation at all levels:

1. Strengthen political commitment and improve the positioning of nutrition in national policies and programmes.

* Use existing and develop new advocacy tools to sensitize decision-makers about the urgency of the problem, the impact on development targets and the opportunity to improve care.
* Advocate for increased resource allocation and support for improved nutrition, in general, and for addressing the nutritional needs of HIV-affected and infected populations.
* Prioritize the needs of children affected and made vulnerable by HIV/AIDS.
Clarify and improve multisectoral collaboration and coordination between agriculture, health, social services, education and nutrition.

2. Develop practical nutrition assessment tools and guidelines for home, community, health facility-based and emergency programmes

* Validate simple tools to assess diet and supplement use including traditional and alternative therapies, nutritional status, and food security so that nutrition support provided within HIV programmes is appropriate to individual needs.
* Develop standard and specific guidelines for nutritional care of individuals, and implementation of programmes at health-facility and community levels.
* Review and update existing guidelines to include nutrition/HIV considerations (e.g., integrated management of adolescent and adult illness, ARV treatment, nutrition in emergencies).

3. Scale-up existing interventions for improving nutrition in the context of HIV

* Accelerate the implementation of the Global Strategy for Infant and Young Child Feeding.
* Renew support for the Baby-friendly Hospital Initiative.
* Accelerate the fortification of staple foods with essential micronutrients.
* Implement WHO protocols for vitamin A, iron, folate, zinc, multiple micronutrient supplementation and management of severe malnutrition.
* Accelerate training and use of guidelines and tools for infant feeding counselling and maternal nutrition in prevention of mother-to-child transmission programmes
* Expand access to HIV counselling and testing so that individuals can make informed decisions and receive appropriate advice and support on nutrition, including in emergency settings.

4. Conduct systematic operational and clinical research to support evidence-based programming

* Develop and implement operational and clinical research to identify effective interventions and strategies for improving nutrition of HIV-infected and affected adults and children.
* Document and publish results and ensure access to lessons learned at all levels.
* Encourage scientific journals to give greater opportunity for publication of operational research and records of good practice.

5. Strengthen, develop and protect human capacity and skills.

* Include funding for nutrition capacity development in HIV scale-up plans.
* Incorporate nutrition into training, including pre-service training, of health, community and home-based care workers. Specific skills such as nutritional assessment and counselling, and programme monitoring and evaluation should be included. Such training should be not favour particular commercial interests.
* Strengthen the capacity of government and civil society to develop and monitor regulatory systems to prevent commercial marketing of untested diets, remedies, and therapies for HIV-infected adults and children.
* Improve the conditions of service and coverage of health workers, especially dieticians and nutritionists, to deliver nutritional services.
* Identify and utilize local expertise to improve response to emergency conditions.

6. Incorporate nutrition indicators into HIV/AIDS monitoring and evaluation plans

* Include appropriate nutrition process and impact indicators for clinical and community surveillance, and for national, regional, and international progress reporting.

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