**2. Magnitude of the problem**

A study in 2010 estimated that more than 925 million people in the world were undernourished and one-third of the global disease burden could be eliminated by adequate nutrition [3]. The greatest burden of malnutrition is seen in the age group of 2–5 years. According to 2014 data, 159 million children were stunted and 50 million were wasted [4]. Among different geographic regions, South Asia and sub-Saharan Africa have the highest global burden of malnutrition. In 2014, they accounted for 25.1 and 32% of stunted children under 5 years of age, respectively [5, 6]. Sub-Saharan Africa suffers from a high burden of undernutrition, affecting 23.2% of its population, and in 2015 this region accounted for 69% of the estimated people living with HIV globally. A review of case records of 4350 children aged 2 – 19 years enrolled in HIV-care programme in Benin, Burundi, Cameroon, Chad, Cote d'Ivoire, Mali and Togo was done in 2011. The mean age was 10 years (IQR 7 – 13). Anthropometric indices that were measured were height-for-age z-score (HAZ) and weight-for-height z-score (WHZ) for children < 5 years and BMI-forage z-score (BAZ) for children >5 years. All values were expressed as z-scores. About 80% of the children were on ART for a median period of 36 months. The prevalence of malnutrition was 42% (95% CI 40–44%). About half of all children in the age group of 2–5 were malnourished, and among children in the age groups of 5–10 and 10–19, the prevalence was 36 and 44%, respectively. The authors then subtyped malnutrition as acute, chronic or mixed. Acute malnutrition was defined as WHZ/BAZ < −2SD and HAZ ≥ −2SD. The prevalence of acute, chronic and mixed malnutrition was 9 (95% CI 6–12%), 26 (95% CI 23–28%) and 7% (95% CI 5–10%), respectively. Acute malnutrition was associated with age < 5 years, male sex, severe immunodeficiency and absence of ART. Chronic malnutrition was most common in children <5 years (37%). The prevalence of chronic malnutrition in the age groups 5–10 and 10-19 years was 24% each. Mixed malnutrition was associated with male sex, age < 5 years, severe immunodeficiency and recent initiation of ART (<6 m) [7]. In another study from Ethiopia, malnutrition was seen in 224 of the 372 children with HIV/AIDS (60.2%). Of all the malnourished children, 67.7% were males and 52.7% were females. In the age group of 2–5 years, 96.3% were malnourished, and in the age groups of 5–10 and 10–15 years, it was 48.3 and 59.2%, respectively [8].

In a study from North India, 56.7% of 102 HIV-positive children presenting to an ART clinic had protein-energy malnutrition (PEM). Children with higher grades of PEM had lower CD4 cell counts [9]. Of the 4105 children initiating ART in TREAT Asia Paediatric HIV Observational Database (TApHOD) cohort, 355 (11.9%) had severe malnutrition (defined as baseline weight-for-height z-score of <−3 if aged 6–60 months or BMI-for-age z-score of <−3 if aged 61 months to 14 years) [10]. This is very high compared with the estimated prevalence of severe malnutrition in the general paediatric population in SE Asia (5.2%) [11]. The risk factors for severe malnutrition were age 6–12 months, male sex and prior diagnosis of tuberculosis [10].

Among adult patients, moderate malnutrition is more common than severe malnutrition. A study done in Salvador, Brazil, looked at prevalence of malnutrition in PLHA in the age group of 20–59 years. One hundred twenty-seven patients were enrolled in the study. Malnutrition (BMI < 18.5 kg/m2 ) was found in 55 (43%) of the subjects and severe malnutrition (BMI < 16 kg/m2 ) in 15%. Lean body mass and fat body mass were lower than the fifth percentile of a reference population in 80 (63%) and 38 (30%) patients, respectively [12]. Another study from Iran compared malnutrition among adults with HIV/AIDS with the general population. One hundred PLHA were enrolled in the study. Mild (BMI 17–18.4 kg/m2 ), moderate (BMI

**31**

*Malnutrition in HIV/AIDS: Aetiopathogenesis DOI: http://dx.doi.org/10.5772/intechopen.90477*

) and severe malnutrition (BMI < 16 kg/m<sup>2</sup>

**3. Impact of HIV-malnutrition: mortality and morbidity**

**4. Aetiopathogenesis of HIV-malnutrition**

**4.1 HIV infection per se and HIV wasting syndrome**

deficiency of important micronutrients like zinc and selenium [13].

15%, respectively. Except for mild malnutrition, all the other figures were significantly higher than that for the general population [13]. Data from the Nutrition for Healthy Living (NFHL) cohort in Boston, USA, reveals some disturbing facts about HIV-malnutrition in the era of HAART. The total prevalence of HIV-associated weight loss and wasting in the cohort was 38%. Both weight loss and wasting were seen in those who were on a robust ART regimen, those who had failed ART and those who were ART-naive. The authors also found that the prevalence of weight loss and wasting had not changed over time and that it was as frequent in 2005 as it

Malnutrition contributes to increased mortality among children, mainly due to infections. Children with severe acute malnutrition had 12 times the risk of dying when compared with well-nourished children of the same age [15]. HIV infection further increases the risk of dying among children with malnutrition. A systematic review and meta-analysis of 17 studies on 4891 children with severe acute malnutrition in sub-Saharan Africa revealed that children with HIV infection were more likely to die than those not infected with HIV (30.4 vs. 8.4%, P < 0.001, relative risk 2.81, 95% CI 2.04–3.87) [16]. Non-immunological factors also contribute to increased mortality among children with malnutrition. These include impaired respiratory excursions due to reduced muscle mass predisposing to chest infections, reduced electrolyte absorption from the gut, impaired renal concentration capacity which puts the child at risk for dehydration and lastly impaired cardiac function that can cause heart failure [17]. The NHFL study showed that for every 1% increase in weight loss since the previous visit, the risk of death rose by 11%. When weight loss was >10% below the baseline weight, the relative risk of death increased nearly sixfold [14].

HIV wasting was included as an AIDS-defining criterion (ADC) in 1987 by the Centers for Disease Control and Prevention (CDC). HIV wasting is defined as an involuntary weight loss of >10% from the baseline and associated with diarrhoea, fever or weakness of ≥30 days duration in the absence of a concurrent illness. HIV wasting is associated with disease progression and death even when patient is on effective ART [18]. Wasting is associated with low serum albumin levels and

The primary cause for weight loss in PLHA is inadequate calorie intake. One of the key factors leading to this is anorexia secondary to elevated levels of proinflammatory cytokines like interleukin-1 (IL-1), interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α). These cytokines also cause a rise in total daily energy expenditure (TEE) due to an increase in resting metabolic rate (RMR) or resting energy expenditure (REE) [19, 20]. RMR may increase by 10–30%, more so in the presence of concurrent infections or high viraemia and increased catabolism of proteins [14, 21–25]. Macallan et al. evaluated patients with HIV/AIDS for TEE, REE and energy intake. The REE was 9.6% higher in HIV-infected men than in HIVnegative men (25.0 vs. 22.8 kcal/kg/d; p = 0.002). But the mean TEE in HIV-infected men was lower than that of the population standard for HIV-negative men between

) were seen in 24, 38 and

16–6.9 kg/m2

had been in 1997 [14].

*Nutrition and HIV/AIDS - Implication for Treatment, Prevention and Cure*

A study in 2010 estimated that more than 925 million people in the world were undernourished and one-third of the global disease burden could be eliminated by adequate nutrition [3]. The greatest burden of malnutrition is seen in the age group of 2–5 years. According to 2014 data, 159 million children were stunted and 50 million were wasted [4]. Among different geographic regions, South Asia and sub-Saharan Africa have the highest global burden of malnutrition. In 2014, they accounted for 25.1 and 32% of stunted children under 5 years of age, respectively [5, 6]. Sub-Saharan Africa suffers from a high burden of undernutrition, affecting 23.2% of its population, and in 2015 this region accounted for 69% of the estimated people living with HIV globally. A review of case records of 4350 children aged 2 – 19 years enrolled in HIV-care programme in Benin, Burundi, Cameroon, Chad, Cote d'Ivoire, Mali and Togo was done in 2011. The mean age was 10 years (IQR 7 – 13). Anthropometric indices that were measured were height-for-age z-score (HAZ) and weight-for-height z-score (WHZ) for children < 5 years and BMI-forage z-score (BAZ) for children >5 years. All values were expressed as z-scores. About 80% of the children were on ART for a median period of 36 months. The prevalence of malnutrition was 42% (95% CI 40–44%). About half of all children in the age group of 2–5 were malnourished, and among children in the age groups of 5–10 and 10–19, the prevalence was 36 and 44%, respectively. The authors then subtyped malnutrition as acute, chronic or mixed. Acute malnutrition was defined as WHZ/BAZ < −2SD and HAZ ≥ −2SD. The prevalence of acute, chronic and mixed malnutrition was 9 (95% CI 6–12%), 26 (95% CI 23–28%) and 7% (95% CI 5–10%), respectively. Acute malnutrition was associated with age < 5 years, male sex, severe immunodeficiency and absence of ART. Chronic malnutrition was most common in children <5 years (37%). The prevalence of chronic malnutrition in the age groups 5–10 and 10-19 years was 24% each. Mixed malnutrition was associated with male sex, age < 5 years, severe immunodeficiency and recent initiation of ART (<6 m) [7]. In another study from Ethiopia, malnutrition was seen in 224 of the 372 children with HIV/AIDS (60.2%). Of all the malnourished children, 67.7% were males and 52.7% were females. In the age group of 2–5 years, 96.3% were malnourished, and in the age groups of 5–10 and 10–15 years, it was 48.3 and 59.2%,

In a study from North India, 56.7% of 102 HIV-positive children presenting to an ART clinic had protein-energy malnutrition (PEM). Children with higher grades of PEM had lower CD4 cell counts [9]. Of the 4105 children initiating ART in TREAT Asia Paediatric HIV Observational Database (TApHOD) cohort, 355 (11.9%) had severe malnutrition (defined as baseline weight-for-height z-score of <−3 if aged 6–60 months or BMI-for-age z-score of <−3 if aged 61 months to 14 years) [10]. This is very high compared with the estimated prevalence of severe malnutrition in the general paediatric population in SE Asia (5.2%) [11]. The risk factors for severe malnutrition were age 6–12 months, male sex and prior

Among adult patients, moderate malnutrition is more common than severe malnutrition. A study done in Salvador, Brazil, looked at prevalence of malnutrition in PLHA in the age group of 20–59 years. One hundred twenty-seven patients were

fat body mass were lower than the fifth percentile of a reference population in 80 (63%) and 38 (30%) patients, respectively [12]. Another study from Iran compared malnutrition among adults with HIV/AIDS with the general population. One hun-

) was found in 55 (43%) of

) in 15%. Lean body mass and

), moderate (BMI

**2. Magnitude of the problem**

**30**

respectively [8].

diagnosis of tuberculosis [10].

enrolled in the study. Malnutrition (BMI < 18.5 kg/m2

the subjects and severe malnutrition (BMI < 16 kg/m2

dred PLHA were enrolled in the study. Mild (BMI 17–18.4 kg/m2

16–6.9 kg/m2 ) and severe malnutrition (BMI < 16 kg/m<sup>2</sup> ) were seen in 24, 38 and 15%, respectively. Except for mild malnutrition, all the other figures were significantly higher than that for the general population [13]. Data from the Nutrition for Healthy Living (NFHL) cohort in Boston, USA, reveals some disturbing facts about HIV-malnutrition in the era of HAART. The total prevalence of HIV-associated weight loss and wasting in the cohort was 38%. Both weight loss and wasting were seen in those who were on a robust ART regimen, those who had failed ART and those who were ART-naive. The authors also found that the prevalence of weight loss and wasting had not changed over time and that it was as frequent in 2005 as it had been in 1997 [14].
