Guidelines>Zambia HIV National Guidelines>

• Prevent weight loss and maintain optimal nutrition status.
• Restore nutritional status for severely malnourished patients to optimize health and reduce stigma.
• Support overweight patients to reduce weight and other associated health risks.

• Periodic nutritional status assessment: Weigh symptomatic patients at least every 2 months and asymptomatic patients every 4 -6 months.
• Energy needs: Increase energy intake for disease stage through consumption of a mixed diet. Refer severely malnourished patients (BMI <18.5) to nutrition clinic for counselling and support with therapeutic foods supplement where possible.
• Asymptomatic patients require 10% more energy than Recommended Daily Allowance (RDA): at least an extra 1 energy-dense snack per day.
• Patients with AIDS symptoms require 20 -30% more energy than RDA:at least an extra of 2-3 energy dense snacks per day.
• Maintain high levels of sanitation, food safety and hygiene.
• De-worm biannually using appropriate broad spectrum anti-helminthic drug such as albendazole or mebendazole , if area is worm infested.
• Maintain physical exercise (walking, jogging, light physical exercise, light household chores) to build or strengthen muscles, increase appetite and health.
• Drink plenty of safe clean water, at least 8 glasses per day.
• Treat all OIs and control symptoms, especially those that interfere with food intake, absorption and utilization. These may include anorexia (loss of appetite), thrush, vomiting, fatigue, taste alterations and fat malabsorption.
• If on medication, manage drug food interactions and side effects by following food drug schedule; use dietary measures to manage side effects. If taking any remedies or supplements, clinician should be informed.

• Goal: to determine severity of nutrition impairment and probable causes. Assessment focuses on information about dietary and anthropometric factors, clinical status bio-medical status, psychosocial factors, and living environment.
• Anthropometric screening: serial measurements of weight, height, mid-upper arm circumference (MUAC), triceps skin-fold thickness
• Examine for presence of oedema
• Body mass index (BMI) = weight (kg)/height (m)². WHO cut-offs: <18.5 = underweight; 18.5-24.9 = normal weight; 25-29.5 = overweight; 30 and above = obese. (Does not apply to pregnant women. MUAC preferred)
• Refer patients who have lost 10% or 6-7 kgs in 1 month to clinician to assess for ART eligibility.
• Rapid loss of >5% of usual body weight over 2 - 3 months associated with OIs and hospitalization. Assess for correctable or treatable conditions.
• Rapid loss of >10% of usual body weight over 2-3 months associated with wasting syndrome or could be side effect of ART.
• Support patients with BMI < 18.5 with therapeutic food supplements (where available) to improve nutrition status or refer to other community support groups offering nutrition services.
• Patients with BMI > 30 should reduce weight without compromising nutrition status: control caloric intake; encourage increased intake of low caloric foods such as vegetable and high fibre diets; restrict intake of polysaturated fats and avoid saturated and trans fats and oils; restrict sugar intake; increase water intake; ensure regular exercise
• Triceps skin-fold thickness: Measure body mass or cell mass at least every 6 months and every 3 months after starting ART. Skin thickness of < 5mm for men and < 8 mm for women indicates risk of malnutrition. Low measurements may indicate undernutrition or change in metabolic functions.
• Mid-upper arm circumference (MUAC): Recommended for adults who cannot stand up for weight and height measurements. Cut-offs: Men <25 cm, women < 22 cm; <16 cm = severe malnutrition, 16-18.5 cm = moderate malnutrition, <22 cm recommended for pregnant women
• Clinical Assessment: Current and past medical history and related clinical examination to establish nutrition risk.
• Assess possible illnesses and deficiencies aggravated by HIV (e.g. thrush, chronic diarrhea, reduced food intake); drugs and/or traditional therapies patient may be taking; lipoatrophy; clinical stage of disease.
• Provide patient with manifestation of deficiency of any nutrient with nutritional advice and supplements where appropriate. In case of key deficit in a micronutrient, provide highly bioavailable multi-micronutrient formulation of 1 RDA.
• Dietary Assessment: proxy indicator of patient's nutrient intake and risk of energy and nutrient deficiency.
• Assess food intolerance (e.g. intolerance to lactose); reduced food intake due to loss of appetite, chewing and swallowing problems, regurgitation, nausea, vomiting or diarrhea, allergies, fatigue, etc.
• Assessment of food intake based on 24 hour recall or by having patient record food consumed over 3 consecutive days. Discourage consumption of dairy products in lactose intolerance clients. When weight has unintentionally declined in 2 -3 months, refer to nutrition clinic. If signs of clinical manifestation, refer to clinician.
• Assess living environment: Identify factors that might be supporting or weakening resolve of the patient. Assess living environment and psychosocial situation. Educate and counsel patient to change unfavourable lifestyle habits that may affect food intake and nutrient absorption and utilization; provide nutritional management.

• HAART should improve overall nutritional status with increase in body weight and intracellular water. If weight unchanged within 6 weeks to 12 months, consider the following causes:
• -Poor adherence
• -Health complications, such as TB
• -Drug resistance
• -Inadequate intake of energy and other nutrients
• -Drug-drug or food-drug interactions
• -Drug side effects
• Patients with BMI <18.5 should be supported with food supplements of high protein/energy or ready to use therapeutic feeds.

• Micronutrients play significant role in immune system functions. Some vitamins are water soluble and cannot be stored in body, while fat soluble vitamins are stored for as long as fat is available.
• According to WHO, there is not sufficient evidence to support need for increased requirements for HIV+ patients. It is recommended that:
• -Patients consume recommended daily allowance of all micronutrients.
• -Consider therapeutic intervention of >1 RDA supplementation, preferably with a multiple micronutrient supplement, for those with a vitamin or mineral deficiency or those vulnerable to micronutrient deficiency.

• HIV+, asymptomatic patients
• Promote healthy diet adequate in energy, protein, fat and other essential nutrients.
• Provide nutrition counseling and support.
• Encourage physical activity and exercise.
• Counsel on hygiene and safe food handling and preparation.
• Encourage patient to seek immediate attention for any digestive and health-related problems to prevent further nutritional and physical deterioration.
• Refer patients with financial constraints to community service providers or support groups.
• Refer patient to clinician for health complications.
• HIV+ patients with weight loss:
• Refer to nutritionist/dietician for counseling.
• Ascertain circumstances that may have led to weight loss.
• For any clinical conditions, refer to physician for further investigation.
• Nutritionist/dietician should provide specific advice on how to maintain intake during these periods.
• Increase intake to promote nutritional recovery following periods of appetite loss, fever or acute diarrhea.
• Minimize nutritional impact of infection by advising on dietary management.
• Advise patients to avoid unhealthy lifestyles, including excessive alcohol consumption, tobacco and illicit drug use, which may affect nutrition.

• EFV : Should be taken on empty stomach when first prescribed. Can later be taken with food if tolerated. Avoid alcohol consumption.
• NVP : Can be taken without regard to food
• ABC : Can be taken without regard to food
• ddI : Take 30 minutes before or 2 hours after eating. Take with water only (taking with food reduces absorption). Do not take with juice. Avoid excessive alcohol consumption
• 3TC : Can be taken without regard to food
• d4T : Can be taken without regard to food
• TDF : Can be taken without regard to food
• AZT : Taking with food may decrease GI side effects (e.g. nausea)
• IDV : Take on empty stomach 1 hour before or 2 hours after meals, or with light non-fat meal. Take with water. Drink at least 1500 ml of fluids daily to prevent kidney stones. Avoid grapefruit juice and St. John's wort.
• LPV/r : Tablets can be taken with or without food, but capsules should be taken with food. Avoid St. John's wort.
• NFV : Take with food, especially fat, to increase absorption. Taking with acidic food or drink will cause bitter taste. Avoid St. John's wort.
• RTV : Take with a meal if possible. Avoid St. John's wort.
• SQV : Always taken with RTV (see RTV )
• INH : Administer with vitamin B6 (pyridoxine) to avoid B6 deficiency and neuropathy.
• Ciprofloxacin : Do not give with iron or zinc-containing supplements (take at least 2 hours apart).

• Goals of nutrition and food interventions vary according to disease stage and whether or not patient taking ART or treatment for infections.
• WHO Stage 1: Person generally well with good performance status. Goal: maintain body weight and ability to fight infections with normal, healthy eating pattern.
• -Provide steady food supply while individual still healthy
• -Provide food rations in food insecure areas including for nutritionally vulnerable pregnant and lactating women
• -Provide advice and support to maintain steady weight and to prevent food and water-borne infection. Check weight at least every 2 months in adults.
• WHO Stage 2: Usually loss of <10% of body weight. Infections such as oral thrush, sore mouth and diarrhoea can occur, resulting in decreased food intake and absorption of nutrients. Patients also may experience nausea and loss of appetite.
• -Refer to physician to treat medical condition(s) that cause decreased intake and absorption of nutrients early, and encourage patients to adjust eating habits by increasing energy-dense food intake eaten in small amounts and reducing fatty and spicy foods.
• -Counsel on management of common nutrition-related symptoms of HIV and OIs.
• -Call for specialized advice of dietician/nutritionist.
• WHO Stages 3 and 4: Weight loss and wasting become serious problems; diarrhoea occurs more frequently and for longer periods. Patients may need assistance with food preparation and special foods and supplements.
• -Provide therapeutic feeding for moderately and severely malnourished adults and children: Therapeutic food formulations like F75 and F100 therapeutic milk, Plumpynut® (RUTF paste), HEPs and locally produced nutrient-dense foods.
• -Assistance in self care, including food preparation should be provided.
• -Manage the side effects (liver damage, kidney stones, peripheral neuropathy) of ART and other medicines such as anti-TB drugs.
• -Call for specialized advice of dietician/nutritionist and physician where services are available.

• Diarrhoea (acute and chronic): loose, watery, and/or more frequent stools.
• Causes: Bacterial, viral, and fungal infections; food poisoning; medications (especially antibiotics); poor absorption of and intolerance to nutrient (e.g. lactose and sugar); malignancies; non-HIV conditions (inflammatory bowel disease, irritable bowel syndrome, etc.)
• Diagnosis: Check stool of ova and parasites, bacteria, and treat pathogens when appropriate. Refer for further evaluation when needed.
• Dietary Management:
• -Drink sufficient fluids such as water, diluted and unsweetened fresh fruit juices.
• -Drink salt and sugar solution.
• -Eat salty foods (e.g., soup) or add extra salt to meals. Once diarrhoea stops, resume normal intake.
• -Eat small frequent meals.
• -Eat fermented foods like maheu, sour porridge.
• -Decrease fatty foods, as high fat intake may cause steatorrhea and worsen diarrhoea. However, high fat meals will decrease diarrhea if it is due to PIs such as NFV , RTV.
• -If milk and dairy products cause cramps, use fermented products like lacto and yoghurt.
• -Include soluble fibre (pectin) by eating foods like bananas, peeled apples and pears, oats, carrots, pumpkin, paw-paw, potatoes.
• -Avoid insoluble fibre such as that in whole grain foods and beans.
• Fat intolerance, diarrhoea or steatorrhea (fat in the stool):
• Causes: Fat malabsorption, incomplete digestion of fat and malnutrition. Refer for further evaluation as needed.
• Dietary Management:
• -Eat soft, mashed, liquid foods like soup, porridge.
• -Eat fruits and vegetables and other low fat foods.
• -Bake, boil, steam or roast food.
• -Squeeze lemon juice on meat and fish to improve digestion; preferable to eat lean meat and to avoid fatty meat.
• -Remove skin from chicken before cooking.
• -Eliminate oil, butter, margarine and foods that contain or were prepared with them.
• -Avoid fatty foods such as potato chips, butter/margarine, mayonnaise and cream.
• Nausea and vomiting: 
• Causes: Medication side effects, infections (e.g. malaria), dirty environment, food with strong aromas, food intolerance (especially for people who do not tolerate lactose, fatty foods and highly seasoned foods)
• Dietary Management:
• -Eat small frequent meals.
• -Eat slowly and chew well.
• -Cool or cold meals better tolerated than hot.
• -Drink diluted and unsweetened fruit juice, especially lemon.
• -Sour or salty foods such as lemons or salty soups better tolerated than sweet foods.
• -Do not lie down immediately after eating.
• -Avoid greasy, high fat or spicy foods.
• -Avoid drinking fluids with meals.
• -Avoid smell of cooking and foods with strong aromas such as cabbage, garlic and onion.
• Taste changes: Food does not taste normal or pleasant
• Causes: Medication side effects (e.g., anti-malarials), illnesses such as colds, flu and malaria, poor mouth hygiene, smoking, glossitis, gingivitis, thrush 
• Dietary Management:
• -Add seasoning to give more flavour to meal.
• -Try different meals to add variety.
• -Practice oral hygiene by brushing teeth after meals.
• -Replace disliked dishes with preferred ones.
• -Use straw to bypass taste buds and eat more frequently.
• -Refer for dental evaluation.
• -Treat thrush, if present.
• Oral candidiasis/thrush: white plaques in mouth, chewing difficulties, dysphagia, odynophagia.
• Causes: Infection, immunosuppression, antibiotic therapy, diabetes, prednisone
• Dietary Management:
• After following standard treatment guidelines, consider the following:
• -Try soft, non-irritating foods such as scrambled eggs, custard, pureed pumpkin, paw-paws or porridge.
• -Fermented food like maheu, lacto (mabisi), yoghurt relieves oral thrush.
• -Suck lump of ice or have ice cold drink before a meal.
• -Practice good oral hygiene.
• -Appropriately add custard to reduce acidity.
• -Use straw to avoid contact with affected part of mouth.
• -Avoid sticky or dry foods such as peanut butter on white bread, popcorn, roasted nuts or dry toast.
• -Avoid sweet or sugary drinks.
• -Avoid hot foods-cold food can be soothing.
• -Avoid acidic foods such as citrus fruit, vinegar and spicy food.
• Loss of appetite, anorexia:
• Causes: Chronic infection (HIV, TB); medications (e.g., anti-malarials); malnutrition; monotonous meals; stress, anxiety and depression; noxious smell and odours (e.g., cosmetic sprays, foods with strong smell such as fish); malignancies
• Dietary Management:
• -Eat with friends or family.
• -Eat small frequent meals and nutritious snacks throughout the day in between meals.
• -Drink high energy, high protein liquids and fruit juices.
• -Try to make meals attractive and appetizing.
• -Eat food with pleasant aroma.
• -Avoid drinking liquids before and during meal.
• -Brush teeth after meal.
• -Avoid fatty foods and sweets.
• -Avoid smoking.
• -Avoid preparing meals or staying in the kitchen.
• -Refer for further evaluation as needed.
• Weight loss: Early diagnosis and treatment of infections crucial. Refer for further evaluation as needed. Weight loss is of concern as it is difficult to reverse.
• Causes: Infections (e.g., TB, malaria), poor appetite, oropharyngeal candidiasis, poor absorption of nutrients due to diarrhoea and other conditions, poor quality of diet, nausea/vomiting, malignancies, diabetes mellitus, thyroid disease, depression, decreased intake of food (due to financial constrictions)
• Dietary Management:
• -Eat regular balanced meals.
• -Eat nutritious snacks between meals such as roasted peanuts, boiled eggs, fruits and sandwiches.
• -Exercise regularly to increase lean body mass and appetite.
• -Increase nutrient density of foods without visibly increasing volume of meal by adding peanut butter, skimmed milk powder, or eggs in soups or porridge.
• -Eat fat if tolerated such as fried meat, chicken, fish, and use oil in cooking.
• Fatigue: Poor performance, inactivity, loss of concentration, looking miserable, burn-out, general malaise
• Causes: pain, illness (e.g. anemia), stress, depression
• Dietary Management:
• -Have someone else prepare food for sick individual to avoid fatigue.
• -Eat food that is easy to prepare and chew.
• -Eat fresh fruits that do not require preparation such as banana, paw-paw, etc.
• -Eat nutritious snacks throughout day.
• -Drink high protein, high-energy liquids such as high energy milk (egg flip), maheu, chibwantu, etc.
• Fever: High temperature, fast breathing, dry mouth, looking ill, feeling lethargic.
• Causes: Infectious processes (e.g. malaria, TB)
• Dietary Management:
• -Eat high energy, high protein meals with plenty of fluids and fruit juice.
• -Drink nutritious liquids often such as milk, sour milk, maheu, chibwantu, munkoyo.
• -Refer to physician for further evaluation as needed.
• Heartburn: Feeling of fullness, discomfort or pain after eating.
• Causes: Antibiotics, anti-inflammatory drugs, gas forming or cold foods, spicy foods and fatty foods
• Dietary Management:
• -Eat small frequent meals.
• -Eat slowly and chew food well.
• -Drink fluids an hour before or after a meal.
• -Eat long before sleeping.
• -Exercise regularly.
• -Avoid gas-forming foods such as beans, carbonated drinks and onion.
• -Avoid greasy, fried and spicy foods.
• -Refer to physician for additional evaluation as needed.
• Constipation:
• Causes: Inadequate fibre or fluid intake, antibiotics
• Dietary Management:
• Increase dietary fibre.
• Increase water intake to at least 8 glasses per day.
• Frequent small meals.
• Exercise regularly.

REFERENCED WITHIN THIS GUIDE

• Introduction