HIV-Infected Children and Nutrition: The Friend and The Foe

*Inaya Hajj Hussein, Lara Youssef, Andrea Mladenovic, Angelo Leone, Abdo Jurjus and Virginia Uhley*

## **Abstract**

The impact of nutrition on HIV-infected children has been evaluated in multiple studies. Our review of the current trends of nutrition-related studies revealed that the focus has moved from simply the disease consequences of HIV to ensuring that antiretroviral therapy-treated children are well nourished to ensure growth and development. This update aims to present the state of the art regarding nutrition of HIV-infected children and the real potential for nutrition to serve as a dynamic therapy in this group. Recent World Health Organization reports indicate that the HIV/AIDS disease is curbing in incidence worldwide despite the high 1.8 million children, less than 15 years, reported in 2017. In addition, the literature supports the complexity and bidirectional relation between nutrition and HIV. HIV infection has a substantial effect on the nutritional status, in particular, the gastrointestinal side effects, which, in turn, have a profound impact on HIV infection. Advances in the field have transformed the course of the disease into a chronic illness, where more attention was given to lifestyle and quality of life including nutrition. However, achievement of food security, nutrition accessibility, and appropriate handling of nutrition-related complications of HIV infection are remarkable challenges, particularly, in resource poor environments, where most HIV infections exist.

**Keywords:** HIV/AIDS, HIV-infected children, nutrition in HIV, nutrition for children, adjunct therapy for HIV

#### **1. Introduction**

Good nutrition is essential for normal growth and development of children, and it is a vital component associated with overall health. Children infected with HIV have known increased nutrient needs to maintain optimal nutrition status. In addition, the focus of nutrition interventions has moved over the past two decades, from simply supporting the patient to ensuring that the treated children are well nourished, since they have the additional nutritional demands of growth and development [1]. Related studies have also shown that nutrition is not only an adjunct therapy but potentially a primary therapy in locations with limited access to antivirals [2].

It is also well established that HIV infection has a substantial impact on nutritional status and that nutritional status has a profound effect on the course of HIV infection [3]. The gastrointestinal side effects of HIV treatments have been well described in the literature [4].

Advances in screening and treatment modalities have decreased incidence and have transformed the course of this disease into a chronic illness [4]. In this respect, more attention has been given to the quality-of-life issues such as nutrition [3]. It is important to note that the nutrition-related complications of HIV infections, especially the achievement of food and nutrition security, are remarkable challenges, particularly, in countries of poor resources, where most HIV-infections exist. In addition, children on highly active antiretroviral therapy (HAART) require higher levels of nutritional supplementation, in particular during the initiation period of the treatment [5]. To deal with such issues, a series of guidelines have been developed by WHO and professional societies. However, the adherence to such guidelines has been reported to have encountered many obstacles in different countries.

#### **2. Epidemiology of HIV/AIDS in children**

Despite the fact that the HIV/AIDS pandemic is curbing, in 2017, there were 36.9 million people living with HIV (35.1 million adults and 1.8 million children <15 years). Only 52% of children living with HIV were receiving lifelong antiretroviral therapy (ART). In addition, 940,000 people died from AIDS-related illnesses in 2017, while AIDS-related deaths have been reduced by more than 51% since the peak in 2004 [6].

It is well established that without treatment, HIV infection causes progressive immunosuppression, due to HIV virus-mediated depletion of CD4+ lymphocytes, leaving patients at risk of developing opportunistic infections and other HIVrelated disorders [7, 8]. Since the mid-1990s, the introduction of highly active antiretroviral therapy (HAART) has remarkably influenced the epidemiology of pediatric HIV type 1 infection [9]. Consequently, the prognosis of HIV-infected children has markedly improved, both in terms of mortality and morbidity [9, 10].

The mother-to-child transmission (MTCT) was basically the focus for developing new and innovative strategies to prevent vertical transmission. In the absence of preventive measures, the risk of transmission is pretty significant as it ranges between 15 and 40%. Multiple factors affect the rate of MCTC transmission; they include maternal viral load and duration of exposure. The viral transfer is also enhanced in the presence of breast lesions or vaginal delivery. In western countries (USA and Europe), the MTCT has dropped to less than 1% in the last 10 years [8]. Such a decline is basically due to the implementation of new HIV management guidelines, which include (a) antenatal testing, (b) antiviral prophylaxis early in pregnancy, (c) elective cesarean delivery before labor, and (d) avoidance of breast feeding [8, 11].

Two developments have had the greatest impact on the outcome of pediatric HIV infection:


Mortality rates in resource-limited environments were 4.5, 6.9, and 7.7% at 1, 2, and 3 years, respectively. These rates are similar to those observed among children in developed settings [12]. Despite these encouraging results and increasing access to

**19**

*HIV-Infected Children and Nutrition: The Friend and The Foe*

**3. HIV infection and malnutrition in children**

ART, mortality remains high for HIV-infected children in low- and middle-income countries. Risk factors for mortality in the first year of ART treatment include young age, low CD4 percent, advanced clinical disease, anemia, and low weight for age [13, 14]. In resource-limited countries, HIV can infect the most productive family members, especially parents, reducing agricultural production and the economic capacity of the household, causing insecure provision of food for children [2].

The cooccurrence of HIV and malnutrition together increases comorbidities and mortality in affected individuals [15]. Severe acute malnutrition (SAM) is of particular concern in children with HIV [1]. SAM is defined by the World Health Organization (WHO) as a weight-for-height z-score of less than −3, or a mid-upper arm circumference (MUAC) of less than 11.5 cm in children aged 6 months to 5 years. It can present as either marasmus (protein energy malnutrition nonedematous), kwashiorkor (edematous disease), or as marasmic-kwashiorkor. However, marasmus is seen more commonly in HIV-positive children. Although the prevalence of children with HIV and severe acute malnutrition (SAM) is variable, mortality from SAM is more than three times higher in HIV-positive children than HIV-negative children. In addition, they have a higher risk of infectious comorbidities and complications [15–17]. Nine out of 10 studies on HIV-infected children, conducted in countries with limited food resources, described low height for age, and all 10 studies reported poor weight gain. Such malnutrition was described

• Chronic malnutrition: In this category, there is small height for age caused by

several in utero infections. Such infections, which can also occur in early childhood, could be coupled with other deficiencies. Such malnutrition has a significant impact on the normal development of 39% or 56 million children less than 5 years [18].

• Acute malnutrition: In this form, there is low weight for height resulting from a recent infection or a deficiency, whereby vital functions are impaired, leading to more mortality. However, the situation could be reversed with the appropriate nutritional support. It affects 9% or 13 million children less than 5 years in

• Underweight: In this group, there is also low weight for age. The child is thin, and it is hard to differentiate it from the two other groups. However, it could be considered as an indicator to follow up on the nutritional status of a child. It has been reported to impact 21% of children below 5 years of age in sub-Saharan Africa (30 million children). In brief, wide regional disparities have been reported in the prevalence of malnutrition in individuals infected with HIV. West and Central Africa are among the most impacted by underweight and acute malnutrition (22 and 11%, respectively), while the highest chronic

The relationship between malnutrition and HIV in children is complex. These two conditions interact and can create a vicious circle of poor health outcomes. Moreover, multiple studies have documented the positive effect of appropriate

malnutrition rates are found in East Africa 42% [18].

**4. Malnutrition and the immune system**

*DOI: http://dx.doi.org/10.5772/intechopen.85417*

under several forms:

sub-Saharan Africa [18].

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

described in the literature [4].

peak in 2004 [6].

HIV infection:

(ART) and

**2. Epidemiology of HIV/AIDS in children**

infection [3]. The gastrointestinal side effects of HIV treatments have been well

Advances in screening and treatment modalities have decreased incidence and have transformed the course of this disease into a chronic illness [4]. In this respect, more attention has been given to the quality-of-life issues such as nutrition [3]. It is important to note that the nutrition-related complications of HIV infections, especially the achievement of food and nutrition security, are remarkable challenges, particularly, in countries of poor resources, where most HIV-infections exist. In addition, children on highly active antiretroviral therapy (HAART) require higher levels of nutritional supplementation, in particular during the initiation period of the treatment [5]. To deal with such issues, a series of guidelines have been developed by WHO and professional societies. However, the adherence to such guidelines has been reported to have encountered many obstacles in different countries.

Despite the fact that the HIV/AIDS pandemic is curbing, in 2017, there were 36.9 million people living with HIV (35.1 million adults and 1.8 million children <15 years). Only 52% of children living with HIV were receiving lifelong antiretroviral therapy (ART). In addition, 940,000 people died from AIDS-related illnesses in 2017, while AIDS-related deaths have been reduced by more than 51% since the

It is well established that without treatment, HIV infection causes progressive immunosuppression, due to HIV virus-mediated depletion of CD4+ lymphocytes, leaving patients at risk of developing opportunistic infections and other HIVrelated disorders [7, 8]. Since the mid-1990s, the introduction of highly active antiretroviral therapy (HAART) has remarkably influenced the epidemiology of pediatric HIV type 1 infection [9]. Consequently, the prognosis of HIV-infected children has markedly improved, both in terms of mortality and morbidity [9, 10]. The mother-to-child transmission (MTCT) was basically the focus for developing new and innovative strategies to prevent vertical transmission. In the absence of preventive measures, the risk of transmission is pretty significant as it ranges between 15 and 40%. Multiple factors affect the rate of MCTC transmission; they include maternal viral load and duration of exposure. The viral transfer is also enhanced in the presence of breast lesions or vaginal delivery. In western countries (USA and Europe), the MTCT has dropped to less than 1% in the last 10 years [8]. Such a decline is basically due to the implementation of new HIV management guidelines, which include (a) antenatal testing, (b) antiviral prophylaxis early in pregnancy, (c) elective

cesarean delivery before labor, and (d) avoidance of breast feeding [8, 11].

Two developments have had the greatest impact on the outcome of pediatric

• The early initiation of ART in HIV-infected infants [11]. Although the mortality rate in HIV-infected children is still considerably higher than the pediatric general population, it has decreased to 0.5–0.9 per 100 children per year in recent years [9].

Mortality rates in resource-limited environments were 4.5, 6.9, and 7.7% at 1, 2, and 3 years, respectively. These rates are similar to those observed among children in developed settings [12]. Despite these encouraging results and increasing access to

• The availability and use of highly effective, combination antiretroviral therapy

**18**

ART, mortality remains high for HIV-infected children in low- and middle-income countries. Risk factors for mortality in the first year of ART treatment include young age, low CD4 percent, advanced clinical disease, anemia, and low weight for age [13, 14]. In resource-limited countries, HIV can infect the most productive family members, especially parents, reducing agricultural production and the economic capacity of the household, causing insecure provision of food for children [2].
