**4.10 Socioeconomic factors**

### *4.10.1 Food insecurity*

Wasting and malnutrition in HIV-positive children is not only due to the HIV disease or opportunistic infections. It is also due to breakdown of family structure and the failure of social and healthcare systems. Food insecurity is defined as a lack of access to sufficient, safe and nutritious food to meet dietary needs and maintain a healthy and active life [98]. Another way of defining it is 'insufficient quantity or quality of food, reductions of food intake, and feelings of uncertainty, anxiety, or shame over food' [99].

There is a high prevalence of food insecurity among PLHA. An American study reported that about 50% of PLHA on ART in San Francisco, Atlanta and Vancouver were food insecure [100, 101]. In the NFHL cohort from Boston, 36.1% participants were classified as 'food insecure' [14]. A study done in Senegal compared the prevalence of food insecurity among general population and PLHA in two different regions of Senegal: Dakar where the predominant source of income was nonagricultural business and Ziguinchor in Casamance province where it was agriculture. The prevalence of food insecurity among PLHA in the two regions was much higher being 84.6 and 89.5%, respectively, than in the general population (16–60%). The prevalence of severe food insecurity was 59.6 and 75.4% in Dakar and Ziguinchor, respectively [102]. Similar findings are reported from both urban and rural settings in other parts of Africa. Among 898 PLHA on ART in Kinshasa, Democratic Republic of Congo, 57% of the people were food insecure and 50.9% were severely food insecure [103]. The prevalence is higher in other studies. In one from Windhoek, Namibia, 92% of 390 PLHA on ART were food insecure, and 67% were severely food insecure [104]. In a big study involving 76,038 HIV-infected people in Western Kenya, the prevalence of food insecurity ranged from 20 to 50% [105]. The prevalence of food insecurity in rural Uganda and North Ethiopia were 74.5 and 40.4%, respectively [106, 107].

Food insecurity is linked to lower educational levels and low socioeconomic status, unemployment, larger household size and number of children [108, 109]. Andrade and colleagues found that daily per capita income correlates well with malnutrition in Salvador, Brazil. They found that for daily per capital incomes of <US\$ 2, US\$ 2–4.99 and US\$ 5–9.99, the prevalence of malnutrition increased by 2.01 (95% CI 1.06–3.81), 1.75 (95% CI 0.92–3.35) and 1.42 (95% CI 0.76–2.65) times, respectively, compared to the patients whose *per capita* household income was US\$ ≥10.00 per day [12]. The presence of even one HIV-positive person in a family pushes the family to food insecurity in Africa [110]. In most of Africa, South America and Asia, women are the primary caregivers in households. They procure foodstuffs, gather firewood, prepare food and feed the children. Not surprisingly, the risk of malnutrition in children increases if the mother has HIV/AIDS. Timely provision of ART to HIV-positive women reduces under-5 mortality rates to those similar to children of HIV-negative women.

HIV/AIDS is a major factor leading to food insecurity. The disease leads to debility of family members in the prime of their life. This leads to loss of jobs, reduced productivity and increased caregiver burden. In turn, food insecurity has many adverse effects on health and well-being of PLHA. It leads to risky coping strategies in households with HIV-positive individuals. Wages get directed to purchase of ART, and many family members may exchange sex for money or food, thereby putting themselves at higher risk of acquiring HIV infection and STDs. It also increases risk of vertical transmission of HIV by risky infant-feeding practices. It increases non-adherence to ART, aggravates adverse effects of ART, and leads to incomplete viral suppression, worsening health and increased mortality [111, 112]. In DRC and Namibia, food insecurity was associated with increased odds of poor adherence to ART (adjusted odds ratio 2.06 and odds ratio 3.84) [103, 104].

#### *4.10.2 Poor weaning practices.*

Mothers' level of education influences occurrence of malnutrition in children. Poor education leads to lack of awareness of the importance of exclusive breast feeding for the first 6 months of the infant's life, failure to introduce complementary feeds at 6 months and limited food diversity. It also contributes to adherence to local taboos with regard to refraining from giving foods of animal origin to children.

**39**

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

In addition, lack of access to food supplements for HIV-positive children also contributes to malnutrition among these children in many parts of Africa [113]. Exclusive breast feeding during first 6 weeks of life resulted in consistently higher z-scores for weight at 52 weeks of age in HIV-infected infants than in those on only top feeds or mixed feeds (difference of 130 g for male children and 110 g for female children) [1].

Malnutrition is considered to be the commonest cause of immunodeficiency in the world. It adversely impacts every aspect of immune function. All these immune dysfunctions are collectively referred to as nutritional-acquired immunodeficiency syndrome (NAIDS). Understanding of malnutrition-related immunodeficiency can

Profound thymic atrophy with depletion of thymocytes and changes in thymic extracellular matrix are seen even in moderate malnutrition. It is however difficult to say whether these changes in thymic function are due to malnutrition *per se* or due to the severe infections frequently associated with malnutrition. Changes in thymic micro-environment like decreased thymic epithelial cells, expansion of extracellular matrix and decreased production of thymic hormone all contribute to thymic depletion. Thymocyte depletion results from increased apoptosis of CD4 and CD8 double-positive, double-negative and single-positive (immature) thymic lymphocytes. Apoptosis is driven by increased circulating levels of glucocorticoids,

Bone marrow cellularity is reduced, its stroma altered and there is limitation of extra-cellular matrix expansion. A study on bone marrow changes in children with PEM showed erythroid hypoplasia/dysplasia in the marrows of 50% children with kwashiorkor, 30% children with marasmic-kwashiorkor and 28.5% children with marasmus [114]. Suppression of cell cycle progression of haematopoietic progenitor cells with cell cycle arrest in G0/G1 phase is seen in protein malnutrition. This results in reduction in red cell and white cell lineages. In addition, bone marrow granulocytes display impaired blastic response to granulocyte-colony stimulating factor (G-CSF) and suboptimal mobilisation on lipopolysaccharide challenge. In protein-deficient mice models, bone marrow mesenchymal cells tend to differentiate into adipose cells, thereby altering the cytokine micro-environment in the bone marrow and compromising haematopoiesis. Despite this, the total number of leucocytes in peripheral blood of children with severe acute malnutrition remains normal. However, the number of dendritic cells is reduced [115]. Mice with transferrin receptor-1 deficiency are unable to absorb adequate iron. This results in

**5. Pathobiology of immunodeficiency in malnutrition**

shed a lot of insight into immunodeficiency of HIV/AIDS.

reduced leptin levels and deficiency of dietary protein and zinc.

impaired T-cell development and fewer mature B cells [116].

has not been shown in humans conclusively.

 Secondary lymphoid tissue in the spleen and lymph nodes shows similar degenerative and hypo-proliferative changes in mouse protein-deficient models. The spleen has a thickened capsule and is deficient in splenocytes and splenic mononuclear cells. Cell cycle arrest, similar to that seen in the bone marrow, is seen. Splenic white pulp is also disorganised. Changes in lymph nodes can be seen even in moderate malnutrition. Zinc and iron deficiencies exaggerate changes caused by protein-energy malnutrition. There is hypoplasia of lymph nodes, decreased number of dendritic cells, macrophages, neutrophils and fibroblasts. The ability of lymph nodes to act as an effective barrier to pathogen spread is compromised. Poor

trafficking of soluble antigens through the lymphoid conduits is also seen. It would be intuitive to assume that like all other lymphoid tissue, the gutassociated lymphoid tissue (GALT) should also be hypoplastic in malnutrition. This *Nutrition and HIV/AIDS - Implication for Treatment, Prevention and Cure*

74.5 and 40.4%, respectively [106, 107].

similar to children of HIV-negative women.

*4.10.2 Poor weaning practices.*

ART (adjusted odds ratio 2.06 and odds ratio 3.84) [103, 104].

There is a high prevalence of food insecurity among PLHA. An American study reported that about 50% of PLHA on ART in San Francisco, Atlanta and Vancouver were food insecure [100, 101]. In the NFHL cohort from Boston, 36.1% participants were classified as 'food insecure' [14]. A study done in Senegal compared the prevalence of food insecurity among general population and PLHA in two different regions of Senegal: Dakar where the predominant source of income was nonagricultural business and Ziguinchor in Casamance province where it was agriculture. The prevalence of food insecurity among PLHA in the two regions was much higher being 84.6 and 89.5%, respectively, than in the general population (16–60%). The prevalence of severe food insecurity was 59.6 and 75.4% in Dakar and Ziguinchor, respectively [102]. Similar findings are reported from both urban and rural settings in other parts of Africa. Among 898 PLHA on ART in Kinshasa, Democratic Republic of Congo, 57% of the people were food insecure and 50.9% were severely food insecure [103]. The prevalence is higher in other studies. In one from Windhoek, Namibia, 92% of 390 PLHA on ART were food insecure, and 67% were severely food insecure [104]. In a big study involving 76,038 HIV-infected people in Western Kenya, the prevalence of food insecurity ranged from 20 to 50% [105]. The prevalence of food insecurity in rural Uganda and North Ethiopia were

Food insecurity is linked to lower educational levels and low socioeconomic status, unemployment, larger household size and number of children [108, 109]. Andrade and colleagues found that daily per capita income correlates well with malnutrition in Salvador, Brazil. They found that for daily per capital incomes of <US\$ 2, US\$ 2–4.99 and US\$ 5–9.99, the prevalence of malnutrition increased by 2.01 (95% CI 1.06–3.81), 1.75 (95% CI 0.92–3.35) and 1.42 (95% CI 0.76–2.65) times, respectively, compared to the patients whose *per capita* household income was US\$ ≥10.00 per day [12]. The presence of even one HIV-positive person in a family pushes the family to food insecurity in Africa [110]. In most of Africa, South America and Asia, women are the primary caregivers in households. They procure foodstuffs, gather firewood, prepare food and feed the children. Not surprisingly, the risk of malnutrition in children increases if the mother has HIV/AIDS. Timely provision of ART to HIV-positive women reduces under-5 mortality rates to those

HIV/AIDS is a major factor leading to food insecurity. The disease leads to debility of family members in the prime of their life. This leads to loss of jobs, reduced productivity and increased caregiver burden. In turn, food insecurity has many adverse effects on health and well-being of PLHA. It leads to risky coping strategies in households with HIV-positive individuals. Wages get directed to purchase of ART, and many family members may exchange sex for money or food, thereby putting themselves at higher risk of acquiring HIV infection and STDs. It also increases risk of vertical transmission of HIV by risky infant-feeding practices. It increases non-adherence to ART, aggravates adverse effects of ART, and leads to incomplete viral suppression, worsening health and increased mortality [111, 112]. In DRC and Namibia, food insecurity was associated with increased odds of poor adherence to

Mothers' level of education influences occurrence of malnutrition in children. Poor education leads to lack of awareness of the importance of exclusive breast feeding for the first 6 months of the infant's life, failure to introduce complementary feeds at 6 months and limited food diversity. It also contributes to adherence to local taboos with regard to refraining from giving foods of animal origin to children.

**38**

In addition, lack of access to food supplements for HIV-positive children also contributes to malnutrition among these children in many parts of Africa [113]. Exclusive breast feeding during first 6 weeks of life resulted in consistently higher z-scores for weight at 52 weeks of age in HIV-infected infants than in those on only top feeds or mixed feeds (difference of 130 g for male children and 110 g for female children) [1].
