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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 43-48

Malnutrition in HIV: Are patients in early stages of disease and with high CD4 counts spared?


1 Department of Medicine, Ahmadu Bello University; Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Infectious Diseases & Clinical Immunology Unit, Department of Medicine, Lagos University Teaching Hospital, Lagos, Nigeria
3 Ahmadu Bello University Teaching Hospital, Zaria; Department of Haematology and Blood Transfusion, Ahmadu Bello University, Zaria, Nigeria
4 Immunology Unit, Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
5 ART Laboratory, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
6 Ahmadu Bello University Teaching Hospital, Zaria; Department of Chemical Pathology, Ahmadu Bello University, Zaria, Nigeria
7 Caritas Catholic Relief Foundation (CCRF) HIV Centre, St Gerard Catholic Hospital, Kaduna, Nigeria
8 Department of Pharmacology and Therapeutics, Ahmadu Bello University, Zaria, Nigeria
9 Department of Clinical Pharmacy and Pharmacy Practice, Ahmadu Bello University, Zaria, Nigeria

Date of Web Publication10-Oct-2019

Correspondence Address:
Dr. Iorhen E Akase
Infectious Diseases & Clinical Immunology Unit, Department of Medicine, Lagos University Teaching Hospital, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssajm.ssajm_24_18

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  Abstract 


Background High incidence of malnutrition have been reported in patients with a moderate and advanced HIV disease, but data on the nutritional status of patients with early and mild HIV infection are lacking. This study compared the nutritional status of antiretroviral therapy (ART)-naïve HIV-positive patients with high CD4 counts receiving care in Kaduna state to HIV negative controls.
Materials and Methods Consecutive 90 consenting HIV-infected adults, who were ineligible for ART in the 2013 treatment guideline, were enrolled alongside 90 age-and-sex-matched HIV seronegative healthy individuals, and compared for body mass index (BMI), hemoglobin, serum albumin, vitamin B12, zinc, and copper.
Results Majority (77%) of participants in both groups were females, slightly younger than the males (ages 39.0 ± 4.0 vs 40.0 ± 2.2 years, P > 0.05). HIV-negative persons had significantly higher nutritional indices (BMI, serum albumin, vitamin B12, zinc, and copper levels) than HIV-infected patients, whereas the indices were worse in WHO clinical stage II than WHO clinical stage I patients. HIV and marital status were significantly associated with malnutrition.
Conclusion WHO clinical stage I/II HIV-infected persons have significantly lower nutritional indices than HIV-negative controls. Significant malnutrition therefore occurs in early HIV infection before the start of anti-retrovirals (ARVs) and the occurrence of opportunistic infections.

Keywords: Early-stage disease, high cd4 count, HIV, malnutrition, treatment naïve


How to cite this article:
Obiako RO, Akase IE, Hassan A, Babadoko A, Musa BO, Balogun Y, Okonkwo L, Yusuf R, Muktar HM, Obadaki M, Abdu-Aguye I, Maiha BB. Malnutrition in HIV: Are patients in early stages of disease and with high CD4 counts spared?. Sub-Saharan Afr J Med 2019;6:43-8

How to cite this URL:
Obiako RO, Akase IE, Hassan A, Babadoko A, Musa BO, Balogun Y, Okonkwo L, Yusuf R, Muktar HM, Obadaki M, Abdu-Aguye I, Maiha BB. Malnutrition in HIV: Are patients in early stages of disease and with high CD4 counts spared?. Sub-Saharan Afr J Med [serial online] 2019 [cited 2024 Mar 29];6:43-8. Available from: https://www.ssajm.org/text.asp?2019/6/1/43/268786




  Introduction Top


Undernutrition or malnutrition in the forms of low body mass index (BMI), anemia, macronutrient, and/or micronutrient deficiencies are common complications of stages III and IV HIV diseases.[1],[2] Poor nutritional status has also been shown to be an independent predictor of immunologic decline, opportunistic infections, and shorter survival in both antiretroviral therapy (ART)-naïve and ART-experienced HIV-infected individuals, particularly at the late stages of the diseases,[3],[4],[5] whereas poverty, decreased food intake, and severe wasting were independently associated with ART nonadherence, rapid progression to AIDS, and increased HIV/AIDS prevalence in many developing countries.[6],[7]

The pathophysiology of malnutrition in HIV infection has been linked to persistent chronic inflammation due to excess release of reactive oxygen and nitrogen species which are produced by activated phagocytes.[8],[9] HIV is believed to induce elaboration of proinflammatory cytokines such as interleukin-1β, interleukin-2, interleukin-6, interleukin-8, Tumor necrosis factor-α, soluble receptors of TNF (sTNF) p-55 and p75, and interferon-gamma. Antiinflammatory cytokines such as IL-1 receptor antagonist, interleukin-4, interleukin-10, and interleukin-13 are produced as well.[10] The resultant milieu creates a persistent catabolic state during which amino acids are continually mobilized from skeletal muscles for hepatic gluconeogenesis and negative nitrogen balance leading to wasting, micronutrient deficiencies, and malnutrition.[11] Persistent prooxidant state resulting from continuous HIV RNA replication and several other proinflammatory processes increases as the disease progresses and persist in all stages of the disease with or without ART.[12],[13] The prooxidant state leads to excessive demand and utilization of endogenous antioxidant micronutrients and their resultant deficiency.[14],[15],[16]

The occurrence of malnutrition is commonly associated with advanced disease and low CD4 counts.[3],[4],[5] It is estimated that HIV-positive patients have 10% higher calorie requirements compared to HIV-negative controls, which increases to 20% to 30% in those with TB or chronic diarrhea.[17] The increase in requirements is the cost of immune response to HIV and prevention of muscle wasting in the setting of advanced disease.[18] The Nutritional support for africans starting antiretroviral therapy (NUSTART) trial identified low CD4 count, low BMI, and mid-arm circumference, and raised C-reactive proteins as risk factors for mortality among malnourished HIV patients.[19]

Data on the incidence of malnutrition among Nigerian patients with early HIV disease are lacking. This study compared the nutritional status of WHO clinical stages I and II ART-naïve HIV-infected patients who were managed according to the 2013 WHO HIV treatment guidelines[20] with healthy HIV-negative controls.


  Materials and methods Top


Study sites and research population

The study was conducted at three sites which are
  1. Nasara Treatment and Care Center, Ahmadu Bello University Teaching Hospital (ABUTH), Shika Zaria, which is a major President’s Emergency Plan for AIDS Relief (PEPFAR) sponsored HIV treatment and support clinic in Northwest Nigeria
  2. Catholic Caritas HIV Treatment, Care and Support Clinics, St Gerard Catholic Hospital (SGCH), Kakuri, Kaduna, which is also a major PEPFAR-sponsored HIV treatment and support clinic in Northwest Nigeria
  3. Healthy HIV-negative individuals were recruited from among hospital workers at ABUTH Shika and SGCH Kakuri, Kaduna (such as attendants, messengers, nurses, administrative, and records staff); family members of patients, and volunteers during HIV awareness and enlightenment campaigns in Kaduna North, Kaduna South and Chikun Local Governments of Kaduna State


The population consisted of
  1. Ninety consecutive WHO clinical stage I/II, ART ineligible (ART-naïve) HIV-infected adults (aged 18–59 years) with CD4+ count ≥520.0 cells/μl, who were enrolled consecutively according to 2013 WHO HIV treatment guidelines.[17]
  2. Ninety age-and-sex-matched healthy HIV seronegative individuals (as controls).


Exclusion criteria for HIV-infected patients and controls were age ≤17 years, ≥60 years, history of alcohol and substance abuse, other viral (hepatitis C virus (HCV), hepatitis B virus (HBV), HIV-2) coinfection, vegetarian diet, chronic hypertension, other immunosuppressive conditions/illnesses (such as diabetes mellitus, steroid therapy, chronic liver, and/or kidney disease), psychiatric disease, and pregnancy. Ethical clearance for the research was granted by the Kaduna State Ministry of Health, Kaduna, and Health Research Ethics Committee of ABUTH, Zaria.

Study design and procedures

A descriptive cross-sectional study conducted from January 2014 to September 2016.

At the various enrollment centers, participants were educated and counseled on the objectives, protocol, and voluntary nature of the study. They were also assured of the confidentiality of their biodata. After informed written consent, sociodemographic data and vital signs (including BMI) were obtained from each participant, followed by collection of blood samples for analyses of plasma HIV RNA load (pVL), CD4+ cell counts, and hemoglobin (for HIV-infected patients), and serum micronutrients (serum albumin, zinc, copper, and vitamin B12) for all participants. The study procedure is outlined in [Table 1].
Table 1 Outline of clinical and laboratory evaluations of study participants

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Data analysis

All the data obtained were recorded and analyzed using the Statistical Package for Social Sciences (SPSS) software version 20 (Chicago, Illinois, USA). Normally distributed quantitative variables were expressed in means and standard deviation, whereas skewed variables were expressed in median and interquartile range (IQR). Categorical variables were expressed in frequencies and percentages. Pearson’s Chi-square test was used to determine associations between two categorical variables. Relationships among means, median, and interquartile ranges were calculated with independent samples mean t-test, median test, and Mann–Whitney U-test, respectively. Stepwise logistic regression analysis was performed to determine most significant sociodemographic predictor(s) of nutritional deficiency, whereas the Pearson correlation coefficient was used to determine significant relationships between pVL and nutritional indices. All analyses were set at two-tailed significance level of P ≤ 0.05 at 95% confidence interval.


  Results Top


Sociodemographics

Both HIV-infected patients and HIV-negative controls were 90 in number, respectively. More than 60% of participants in both groups were in the age group of 20 to 40 years. The female-to-male ratio was 3:1; the females were slightly younger (aged 39.0 ± 4.0 years) than the males who were aged 40.0 ± 2.2 years (P > 0.05). Majority of participants were married, most particularly among HIV-negative controls (P ≤ 0.05). Although majority also attained secondary education, more (37.8%) HIV-infected patients attained tertiary education than HIV-negative controls (11.1%) (P ≤ 0.05). Also, more than 60% in each group were gainfully employed, with the HIV-infected persons having more income than HIV-negative controls (P ≤ 0.05), although all the participants were of low socioeconomic group as none of them earned above fifty thousand nairas (N50,000.00) [Table 2].
Table 2 Baseline characteristics of study population

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Nutritional indices of the study population

Healthy HIV-negative controls had significantly higher nutritional indices (BMI, serum zinc, copper, vitamin B12, and albumin) than HIV-infected patients (P ≤ 0.05), except hemoglobin levels which were insignificantly higher (P > 0.05) [Table 3]. HIV and marital status were significantly associated with malnutrition on logistic regression analysis [Table 4], whereas pVL had a significant negative correlation with serum zinc (r = −0.917, P = 0.00), copper (r = −0.756, P = 0.02), and vitamin B12 (r = −0.880, P = 0.00) on Pearson’s coefficient analysis.
Table 3 Comparison of nutritional indices between ART-naïve HIV infected patients and Healthy HIV negative controls.

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Table 4 Logistic regression of socio-demographic factors associated with malnutrition

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Differences in characteristics of WHO clinical stages I and II HIV infected patients

Sixty-six (73%) and 24 (27%) HIV-infected patients were in WHO clinical stages I and II respectively. All patients with stage I had no symptoms, whereas stage II patients had unexplained loss of less than 10% of body weight and herpes zoster. At the time of evaluation, the patients’ median duration of HIV diagnosis was 4 months (IQR of 1–12 months), the median CD4+ count was 704.0 cells/μl (IQR of 600.0–880.0 cells/μl), and median pVL of 27,105.0 copies/ml (IQR of 6346.0–955,514.0 copies/ml), respectively. Patients in WHO clinical stage I had significantly shorter duration of HIV diagnosis and lower pVL copies, but significantly higher CD4+ cell counts and nutritional indices (such as serum zinc, copper, albumin, and vitamin B12) than patients in WHO clinical stage II (P ≤ 0.05). Other nutritional indices such as BMI and hemoglobin were also insignificantly higher in WHO clinical stage II (P > 0.05) [Table 5].
Table 5 Differences in duration of HIV diagnosis, plasma RNA load, CD4+ cell counts and nutritional indices between WHO clinical stages I and II HIV infected patients

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  Discussion Top


The present study compared nutritional status of people with early HIV infection and disease (i.e., WHO clinical stages I and II) and healthy HIV negative persons. To our knowledge, this is the first study on nutritional indices of ART-naïve HIV-infected persons managed according to the 2013 WHO HIV treatment guidelines in Nigeria.[20] Most of our patients were asymptomatic and their CD4+ cell counts were within reference values for healthy Nigerians (365–1571 cells/μl),[21] western Europeans (500–2000 cells/μl),[22] Ugandans (559–2333 cells/μl),[23] and Indians (430–1740 cells/μl).[24] To reduce confounders, the patients were compared with HIV-negative persons who were matched for age and sex, although a higher number of HIV patients had tertiary education, were employed, and also earned higher income than HIV-negative controls. This observation suggested that our cohort of HIV-infected patients were more affluent than HIV-negative controls, which is in contrast to most studies among sub-Saharan Africa, in which the HIV-infected study participants belong to a group classified as food insecure[25] defined as not having access at all times to enough food for an active and healthy lifestyle.[26] The fact that most of the study participants’ BMI (including the HIV-infected patients) were within the “normal to overweight” reference values of the WHO classification of nutritional status[27],[28] can be interpreted as evidence of self-sufficiency in food intake. Also, majority of them were married possibly explaining the importance of marital status as a significant sociodemographic predictor of nutritional status in this study.

Yet despite the “favorable” BMI and marital status of our patients, some of them still had mild anemia, moderate hypoalbuminemia, and severe micronutrient deficiencies compared with HIV-negative healthy controls, and with healthy Iranians,[29] thus the reaffirming the importance of early nutrition risk assessment for HIV-infected persons,[30] irrespective of their clinical stage or ART status.[31]

The progression of untreated HIV infection to HIV disease is believed to be responsible for the differences in characteristics of WHO clinical stages I and II HIV-infected patients in this study. The higher pVL and lower CD4+ cell counts found in patients in WHO clinical stage II are thought to be due to increased HIV transcription and replication and subsequent free-radical-induced T-cell necrosis or apoptosis, and immune dysfunction.[9],[10],[13],[32] The lower levels of nutritional indices found among stage II patients can also be attributed to increased free-radical production and oxidative stress,[12],[32] which are believed to maintain a chronic hypercatabolic state and depletion of endogenous antioxidants such as copper/zinc-dependent superoxide dismutase enzyme, albumin, and repair and de novo enzymes.[14],[15],[16] These phenomena explain the significant negative correlations between pVL and nutritional indices such as zinc, copper, vitamin B12, and albumin in this study.

The outcome of this study has shown that the HIV-infected person has some degree or form of malnutrition, irrespective of clinical staging, level of CD4+ cell count or pVL, and therefore requires immediate ART, in addition to food and micronutrient supplementation. Early use of ART as is currently recommended by the current guidelines,[33] and the consequent reduction in inflammation is important in optimizing nutritional requirements in HIV patients.

Further longitudinal studies are required to compare the nutritional status of HIV-infected persons treated with ART according to current guidelines with and/or without food/micronutrient supplementation.


  Conclusion Top


The results of this study have shown that malnutrition, particularly micronutrient deficiencies and hypoalbuminemia, are common among antiretroviral naïve patients with early stages of HIV infection. Nutritional or micronutrient supplementation should be an integral component of the HIV treatment regimen, particularly in resource-limited countries such as Nigeria and other developing economies.


  Limitation Top


The limitation of the study was our inability to determine the serum levels of endogenous antioxidants (glutathione enzyme complex, uric acid, bilirubin, and catalases).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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