Impact of protein supplementation and care and support on body composition and CD4 count among HIV-infected women living in rural India: results from a randomized pilot clinical trial

Inclusion of nutritional counseling and mental health services in HIV/AIDS management: A paradigm shift

Human immunodeficiency virus (HIV) infection is a public health challenge that can degenerate into acquired immunodeficiency syndrome (AIDS) if not properly managed. HIV infection shortens life expectancy to about 5 to 10 years compared to noninfected individuals. People living with HIV/AIDS (PLWHA) are prone to several health challenges as a result of a deranged immune system culminating in high morbidity and mortality. Depression is a common feature of PLWHA. Depression heightens the emergence of opportunistic infections in HIV-infected individuals, accelerates the progression to AIDS, and increased suicidal tendencies, morbidity, and mortality. Food insecurity with its resultant undernutrition contributes to HIV/AIDS-related deaths. Undernourished PLWHA are more prone to opportunistic infections due to poor immunity. Interestingly, proper diet intake can boost immunity, slow the progression of AIDS and opportunistic infections, enhance body weight, and retard depression tendencies. Undernutrition can also be ameliorated by incorporating nutritional counseling and oral nutrient supplementation in routine HIV/AIDS checkups. Therefore, to increase HIV/AIDS management outcomes, the integration of nutrition counseling, dietary supplements, and mental health services should be embraced. Thus, HIV/AIDS care centers should amplify these services. In this article, we isolated relevant studies from various databases, illuminated the interwoven relationship between HIV/AIDS, depression, and undernutrition, and also reemphasized the need for adequate nutritional intervention in the battle against HIV/AIDS. Thus, this study provides a reawakening call to focus on incorporating nutritional guides and mental health care in HIV/AIDS management protocols.

Lean Mass Improvement from Nutrition Education and Protein Supplementation among Rural Indian Women Living with HIV/AIDS: Results from Cluster Randomized Factorial Trial at 18-Month Follow-Up

Loss of lean muscle mass impairs immunity and increases mortality risk among individuals with HIV/AIDS. We evaluated the relative contributions of protein supplementation and nutrition education on body composition among 600 women living with HIV/AIDS in rural Andhra Pradesh, India. We conducted a cluster randomized controlled 2 × 2 factorial trial lasting six months with follow up at twelve and eighteen months. Interventions occurred in the Nellore and Prakasam regions of Andhra Pradesh by trained village women, ASHA (Accredited Social Health Activists), and included: (1) the usual supportive care from ASHA (UC); (2) UC plus nutrition education (NE); (3) UC plus nutritional protein supplementation (NS); (4) combined UC plus NE plus NS. A Bioimpedance Analyzer Model 310e measured body composition. SAS 9.4 analyzed all data. Mixed models using repeated measures evaluated lean mass change from baseline as primary and fat weight and total weight as secondary outcomes. Lean mass change was significantly associated with NS (p = 0.0001), NE (p = 0.0001), and combined NS plus NE (p = 0.0001), with similar associations for secondary outcomes. Stronger associations for total weight were observed with greater ART adherence. Nutritional interventions may improve physiologic response to HIV. Significant increases in lean mass resulted from independent and combined protein supplementation and nutrition education.

The Effect of Community-Based Nutritional Interventions on Children of Women Living With Human Immunodeficiency Virus in Rural India: A 2 × 2 Factorial Intervention Trial

BACKGROUND

Malnutrition is a common clinical concern among children in low-income communities affected by human immunodeficiency virus (HIV). We examined the effect of a community-based nutritional intervention on anthropometric and clinical outcomes of children of women living with HIV in rural India.

METHODS

We assigned women living with HIV and their child (oldest 3-8 years) to 1 of 4 programs: (1) community-based HIV care program, (2) program 1 + nutrition education, (3) program 1 + food supplement, and (4) all elements of programs 1-3. Study data were collected at baseline and months 6, 12, and 18. We applied mixed-effects modeling with restricted maximum likelihood estimation to examine changes in weight (all children) and CD4+ T-cell counts (children with HIV only).

RESULTS

Overall, 600 mother-child pairs were enrolled (150/group) with 100% retention at follow-up visits. Approximately 20% of children were living with HIV. Children in program 4 had higher weight gain than those in programs 1, 2, and 3 at all time points (adjusted P < .001). We found a higher increase in CD4+ T cells across all time points among participants in programs 3 and 4 compared with program 1 (adjusted P < .001). Factorial analysis suggested a synergistic effect of combining nutrition education and food supplements for weight gain but not for increase in CD4+ T cells.

CONCLUSIONS

A combination of nutrition education and food supplements provided to women living with HIV significantly increased weight and CD4+ T cells, and such interventions can be integrated into HIV-care programs in low-income settings.

Sustained Effect of a Community-based Behavioral and Nutrition Intervention on HIV-related Outcomes Among Women Living With HIV in Rural India: A Quasi-experimental Trial

BACKGROUND

Women living with HIV (WLH) in rural communities face challenges to obtaining treatment and accurate disease-related information. Nutritional deficits exacerbate disease progression.

SETTING

WLH were recruited from primary health centers in rural India.

METHOD

A quasi-experimental trial of a comprehensive Accredited Social Health Activist (Asha)-supported intervention compared 4 distinct Asha-based programs [(1) standard education (SE) alone; (2) nutrition education (+NE); (3) nutrition supplements (+NS); or (4) nutrition education and nutrition supplements (+NENS)] on key disease and nutrition-related outcomes [CD4 count, body mass index (BMI), serum albumin, and hemoglobin]. Assessments occurred at baseline, and months 6 (immediately after intervention), 12, and 18. Multilevel modeling examined effects of program (group) over time.

FINDINGS

Among 600 WLH enrolled (n = 150 per arm), mean age, CD4 count, and BMI (kg/m) were 34.31, 447.42, and 20.09, respectively, at baseline. At 18-month follow-up, program 4 (+NENS) experienced greatest improvements in CD4 counts compared with program 1 (+SE) [adjusted difference = 223.81, 95% confidence interval (CI): 170.29 to 277.32]. For BMI, programs 3 (+NS; adjusted difference = 2.33, 95% CI: 1.39 to 3.26) and 4 (+NENS; adjusted difference = 2.14, 95% CI: 1.17 to 3.12) exhibited greater gains compared with program 1 (+SE). Programs 3 and 4 were not significantly different from each other (adjusted difference = -0.18, 95% CI: -1.12 to 0.76). Hemoglobin and serum albumin also improved over time; program 4 (+NENS) exhibited the greatest gains.

CONCLUSIONS

A low-cost Asha-supported behavioral and nutritional intervention improved outcomes for WLH. Gains were sustained at 18-month follow-up. Similar approaches may help improve HIV and other infectious disease-related outcomes in vulnerable populations.

Chronic Disease Self-Management Challenges among Rural Women Living with HIV/AIDS in Prakasam, Andhra Pradesh, India: A Qualitative Study

Rural women living with HIV/AIDS (WLHA) in India experience challenges self-managing HIV/AIDS in their rural communities. The purpose of this qualitative study was to explore factors influencing their care and antiretroviral treatment (ART) adherence. Themes that emerged from the qualitative focus groups among WLHA (N = 24) in rural Prakasam, Andhra Pradesh, India, included: (1) coming to know about HIV and other health conditions, (2) experiences being on ART, (3) challenges maintaining a nutritious diet, (4) factors affecting health care access and quality, and (5) seeking support for a better future. Chronic disease self-management in rural locales is challenging, given the number of barriers which rural women experience on a daily basis. These findings suggest a need for individual- and structural-level supports that will aid in assisting rural WLHA to self-manage HIV/AIDS as a chronic illness.

Taking stock of 10 years of published research on the ASHA programme: examining India's national community health worker programme from a health systems perspective

BACKGROUND

As India's accredited social health activist (ASHA) community health worker (CHW) programme enters its second decade, we take stock of the research undertaken and whether it examines the health systems interfaces required to sustain the programme at scale.

METHODS

We systematically searched three databases for articles on ASHAs published between 2005 and 2016. Articles that met the inclusion criteria underwent analysis using an inductive CHW-health systems interface framework.

RESULTS

A total of 122 academic articles were identified (56 quantitative, 29 mixed methods, 28 qualitative, and 9 commentary or synthesis); 44 articles reported on special interventions and 78 on the routine ASHA program. Findings on special interventions were overwhelmingly positive, with few negative or mixed results. In contrast, 55% of articles on the routine ASHA programme showed mixed findings and 23% negative, with few indicating overall positive findings, reflecting broader system constraints. Over half the articles had a health system perspective, including almost all those on general ASHA work, but only a third of those with a health condition focus. The most extensively researched health systems topics were ASHA performance, training and capacity-building, with very little research done on programme financing and reporting, ASHA grievance redressal or peer communication. Research tended to be descriptive, with fewer influence, explanatory or exploratory articles, and no predictive or emancipatory studies. Indian institutions and authors led and partnered on most of the research, wrote all the critical commentaries, and published more studies with negative results.

CONCLUSION

Published work on ASHAs highlights a range of small-scale innovations, but also showcases the challenges faced by a programme at massive scale, situated in the broader health system. As the programme continues to evolve, critical comparative research that constructively feeds back into programme reforms is needed, particularly related to governance, intersectoral linkages, ASHA solidarity, and community capacity to provide support and oversight.

Randomized controlled trial of a community-based intervention on HIV and nutritional outcomes at 6 months among women living with HIV/AIDS in rural India

OBJECTIVE

To assess the impact of nurse-led Asha (Accredited Social Health Activist)-support behavioral and nutritional intervention among women living with HIV/AIDS (WLH/A) in rural India.

DESIGN

Cluster randomized controlled trial.

METHODS

Sixteen Primary Health Centers serving WLH/A in Andhra Pradesh were grouped into four regional clusters that were randomly allocated into one of four arms. All four groups included Asha-support and consisted of: Asha-support only (control group); nutrition education; nutrition supplementation; and the combination of supplementation and education. Differences between baseline and 6-month follow-up for key physiological outcomes (BMI, CD4 cell count) were analyzed using factorial mixed models that accounted for geographic clustering.

RESULTS

At 6 months, all groups improved CD4 cell count: Asha only [mean difference score (D) = 343.97, standard deviation (SD) = 106.94], nutrition education (D = 356.15, SD = 0.69), nutrition supplement (D = 469.66, SD = 116.0), and nutrition supplement and education (D = 530.82, SD = 128.56). In multivariable models, Asha-support and nutrition, and Asha-support and nutrition supplement interventions demonstrated independent significant improvements in CD4 cell count; the interaction term was significant [estimate = 529.9; 95% confidence interval (CI) 512.0, 547.8; P = 0.006]. BMI also increased for all groups: Asha only (D = 0.95, SD = 0.82), Asha and nutrition education (D = 1.28, SD = 0.53), Asha and nutrition supplement (D = 2.38, SD = 0.60), nutrition supplement, and nutrition supplement and education (D = 2.72, SD = 0.84). Nutrition supplementation and nutrition education demonstrated independent effects on BMI; the interaction term was not significant (estimate = 0.27; 95% CI = 2.5, 2.7; P = 0.80).

CONCLUSION

Interventions supported by community workers were efficacious at improving physiological outcomes and may be beneficial at meeting critical healthcare needs of vulnerable WLH/A in India.

Changes in Health and Antiretroviral Adherence Among HIV-Infected Adults in Kenya: Qualitative Longitudinal Findings from a Livelihood Intervention

This longitudinal qualitative study sought to understand how and why a livelihood intervention affected the health and health behaviors of HIV-infected Kenyan adults. The intervention included a microfinance loan, agricultural and financial training, and a human-powered water pump. In-depth interviews were conducted at two time points with intervention and control participants and program staff. We double coded interviews (n = 117) and used thematic content analysis of transcripts following an integrative inductive-deductive approach. Intervention participants described improvements in HIV health, including increased CD4 counts and energy, improved viral suppression, and fewer HIV-related symptoms. Better health was linked to improved clinic attendance and ART adherence through several mechanisms: (1) reductions in food insecurity and abject hunger; (2) improved financial stability; (3) improved productivity which enhanced social support; (4) better control over work situations; and, (5) renewed desire to prioritize their own health. Livelihood interventions may improve health by influencing upstream determinants of health behavior including food security and poverty.

The impact of nutritional status and nutrition supplementation on outcomes along the HIV treatment cascade in the resource-limited setting

PURPOSE OF REVIEW

This review proposes to examine the role of nutrition (defined at body mass index, food security or nutrition interventions) in each of the steps of the treatment cascade for HIV.

RECENT FINDINGS

Food insecurity was found to be associated with increase in risk behaviors, with decreased retention in care and with lower adherence to antiretroviral therapy; fewer studies looked at the role of baseline body weight on outcomes such as mortality. Studies of nutrition interventions had more complex outcomes but improvement in nutritional status was the outcome that was most commonly identified.

SUMMARY

Nutrition has an important role to play in the current care of HIV-infected individuals and can have an impact on the treatment cascade. Food in security, which may be reversed by the provision of food, is of particular interest as studies suggest associations with multiple outcomes.

Effect of garlic powder consumption on body composition in patients with nonalcoholic fatty liver disease: A randomized, double-blind, placebo-controlled trial

Background:

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease that is becoming a public health problem in recent decades. Obesity and overweight play a key role in NAFLD pathogenesis. Thus, weight loss (especially body fat mass) is one component of therapeutic strategies in NAFLD. Results from experimental studies have shown that garlic (Allium sativum L.) can reduce body weight and body fat mass. However, the effect of garlic on body fat mass and weight in the human population, which is addressed in this study, is still obscure.

Materials and Methods:

In this clinical trial, 110 subjects with NAFLD were randomly assigned to the intervention or the control group. The intervention group received two garlic tablets (containing 400 mg of garlic powder) daily while the control group received placebo tablets. Dietary intake and physical activity of participants were obtained by a validated questionnaire. Body composition was measured by bioelectrical impedance analysis. Data were analyzed using SPSS software version 16.

Results:

In the intervention group, significant reductions were observed in body weight and body fat mass (P < 0.05). We also observed a significant reduction in body weight in the control group, but there were no significant changes in total body water and lean body mass in both groups (P > 0.05). In the intervention group, the percentage change in body weight was significantly greater than the control group (−2.6 vs. −0.7, P = 0.02). No serious side effects associated with the intervention were reported.

Conclusion:

Our trial suggests that garlic supplemfrom experimental studies have shown thatentation can reduce body weight and fat mass among subjects with NAFLD.

Daily consumption of ready-to-use peanut-based therapeutic food increased fat free mass, improved anemic status but has no impact on the zinc status of people living with HIV/AIDS: a randomized controlled trial

Background

Food insecurity in sub-Saharan Africa and malnutrition constitute the main obstacles for successful treatment of people living with HIV/AIDS (PLWH). The aim of this study was to assess the effect of consuming daily 100 g RUTF (ready-to-use therapeutic food) as supplement, on body composition, anemia and zinc status of hospitalized PLWH in Senegal.

Methods

A Controlled clinical trial was conducted in 65 PLWH randomly allocated to receive either standard hospital diet alone (Control group: n = 33), or the standard diet supplemented with 100 g RUTF/day (RUTF group: n = 32). Supplementation was continued at home during 9 weeks. Individual dietary intakes were measured and compared to the Recommended Dietary Allowances. Body composition was determined using Bio-Impedance Analysis. Hemoglobin was measured by HemoCue and plasma zinc (PZ) concentration by atomic absorption spectrometry. PZ was adjusted to infection (CRP and α1-AGP). All measures were conducted on admission, discharge and after 9 weeks home-based follow up.

Results

34 and 24 % of the patients in RUTF and Control groups were suffering from severe malnutrition (BMI < 16 kg/m²), respectively. In both groups, more than 90 % were anemic and zinc deficiency affected over 50 % of the patients. Food consumed by the Control group represented 75, 14 and 55 % of their daily recommended intake (DRI) of energy, iron and zinc, respectively. When 100 g of RUTF was consumed with the standard diet, the DRI of energy and zinc were 100 % covered (2147 kcal, 10.4 mg, respectively), but not iron (2.9 mg). After 9 weeks of supplementation, body weight, and fat-free mass increased significantly by +11 % (p = 0.033), and +11.8 % (p = 0.033) in the RUTF group, but not in the Control group, while percentage body fat was comparable between groups (p = 0.888). In the RUTF group, fat free mass gain is higher in the patients on ART (+11.7 %, n = 14; p = 0.0001) than in those without ART (+6.2 %, n = 6; p = 0.032). Anemia decreased significantly with the supplementation, but zinc status, measured using plasma zinc concentration, remained unchanged.

Conclusion

Improving PLWH’ diet with 100 g RUTF for a long period has a positive impact on muscle mass and anemia but not on the zinc status of the patients.

Trial number

NCT02433743, registered 29 April 2015.

Food Insecurity and Its Relation to Psychological Well-Being Among South Indian People Living with HIV

Food insecurity (FI) and its link with depression and quality of life (QOL) among people living with HIV (PLHIV) in India are not well-documented. We analyzed cohort data from 243 male and 129 female PLHIV from Bengaluru, and found 19 % of men and 26 % of women reported moderate or severe FI over a 6-month period. Women reported higher mean depression than men, and lower mean QOL. In multivariate analyses adjusting for HIV stigma and demographic covariates, both male and female PLHIV with moderate to severe FI showed lower mean QOL than those reporting mild to no FI. Male but not female food insecure participants also had higher depression scores in adjusted regression analyses. As ART has improved the physical health of PLHIV, more effort is being invested in improving their psychological well-being. Our results suggest such interventions could benefit from including nutritional support to reduce FI among PLHIV.

ASHA-Life Intervention Perspectives Voiced by Rural Indian Women Living With AIDS

In this focus group study, we explored the experiences of 16 rural women living with AIDS (WLA) who participated in the Asha-Life (AL) intervention to gain an understanding of the environmental, psychosocial, and cultural impact of the AL on their lives. Four themes emerged among AL participants: (a) the importance of tangible support, (b) need for social support, (c) ongoing challenges to accessing antiretroviral therapy (ART), and (d) perspectives on future programs. Our research findings support the development of future programs targeting mother-child dyads which emphasize nutritional knowledge, while reducing barriers to receiving ART, and physical, emotional, and financial support.

Nutrition assessment, counseling, and support interventions to improve health-related outcomes in people living with HIV/AIDS: a systematic review of the literature

BACKGROUND

Although numerous studies have shown that severe to moderate wasting at the time of antiretroviral therapy initiation is strongly predictive of mortality, it remains unclear whether nutritional interventions at or before antiretroviral therapy initiation will improve outcomes. This review examines data on nutrition assessment, counseling, and support interventions in resource-limited settings.

METHODS

We identified articles published between 2005 and 2014 on the effectiveness of nutrition assessment, counseling, and support interventions, particularly its impact on 5 outcomes: mortality, morbidity, retention in care, quality of life, and/or prevention of ongoing HIV transmission. We rated the overall quality of individual articles and summarized the body of evidence and expected impact for each outcome.

RESULTS

Twenty-one articles met all inclusion criteria. The overall quality of evidence was weak, predominantly because of few studies being designed to directly address the question of interest. Only 2 studies were randomized trials with no food support control groups. The remainder were randomized studies of one type of food support versus another, cohort (nonrandomized) studies, or single-arm studies. Ratings of individual study quality ranged from "medium" to "weak," and the quality of the overall body of evidence ranged from "fair" to "poor." We rated the expected impact on all outcomes as "uncertain."

CONCLUSIONS

Rigorous better designed studies in resource-limited settings are urgently needed to understand the effectiveness of nutrition assessment and counseling alone, as well as studies to understand better modalities of food support (targeting, timing, composition, form, and duration) to improve both short- and long-term patient retention in care and treatment, and clinical outcomes.

Understanding Health Needs and Perspectives of Middle-Aged and Older Women Experiencing Homelessness

OBJECTIVES

Middle-aged and older homeless women have unique health and social service delivery needs; yet, limited research has been conducted in this area. The purpose of this study was to assess perspectives among prefrail and frail, middle-aged and older homeless women.

DESIGN AND SAMPLE

Focus group methodology was conducted to assess perspectives among these homeless women (N=20) aged 43 to 62.

MEASURES

Sociodemographic and frailty characteristics were assessed by structured instruments, along with mobility, assistive device use and falls.

RESULTS

The average age was 53.4; the majority of the sample was African-American (70%). In total, 60% reported living in a shelter for the last 30 days, while 20% were unsheltered. The majority of the sample reported walking independently (80%) and not using an assistive device (65%). Over one third (35%) fell in the last 30 days and 70% fell in the last year. Content analysis revealed several themes that included (1) health care needs and challenges experienced; (2) perspectives on sexual decision making; (3) employment difficulties; (4) existing support systems; and (5) development of future program planning.

CONCLUSIONS

Future research development and implications are discussed.

Medication Adherence and Health Outcomes of People Living with HIV Who Are Food Insecure and Prescribed Antiretrovirals That Should Be Taken with Food

INTRODUCTION

Food insecurity is a well-established predictor of poor health outcomes. Antiretroviral therapies (ARTs) that should be taken with food to increase bioavailability may further challenge food insecure patients. This study examined factors associated with antiretroviral adherence and HIV viral suppression among people living with HIV who are food insecure and prescribed medications that require food.

METHODS

A community sample of 313 men and 105 women who experienced food insecurity in the previous month and were currently taking ART completed computerized interviews, urine screening for drug use, prospective biweekly unannounced pill count adherence assessments, and obtained their HIV viral load and CD4 cell counts from medical records.

RESULTS

Individuals taking ART regimens that should be taken with food were significantly more likely to be unemployed, were living longer with an HIV diagnosis, had lower CD4 cell counts, poorer HIV suppression, and endorsed more beliefs that taking medications was necessary for their health. Multivariable regression models controlling for potential confounding factors showed that receiving ART that requires food was significantly related to poorer ART adherence and unsuppressed HIV in this food insecure sample.

CONCLUSION

People living with HIV who are food insecure likely experience multiple facets of poverty that challenge their medication adherence, but food insecurity is the only such factor that is directly related to the pharmacokinetics of some antiretroviral medications. Achieving optimal treatment outcomes for HIV infection will require routine assessment of access to food when determining patient-tailored ART regimens.