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A Three-Course Meal -- 2. The Main Course: Healthy Eating

Part of A Practical Guide to Nutrition for People Living With HIV

October 2007

Building a Healthy Diet

Food is the foundation of nutritional health. Nothing can replace food. It can be supplemented, adjusted, increased or decreased, but not entirely replaced. Food provides the building blocks of carbohydrates, proteins and fats (the macronutrients), as well as vitamins and minerals (the micronutrients). The best way to make sure you're getting all of these nutrients is by eating a wide variety of healthy foods every day.

Canada's Food Guide will give you the basics of healthy eating.

Most countries have a food guide to help people make good decisions around food choices. Canada's Food Guide is divided into a rainbow of four food groups:

  • vegetables and fruits
  • grain products
  • milk products and alternatives
  • meat and alternatives

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The 2007 food guide recommends the following daily servings of each food group:

  • at least 7 servings of vegetables and fruits
  • 6 to 8 servings of grain products
  • 2 to 3 servings of milk products and alternatives
  • 2 to 3 servings of meats and alternatives

The general version of Canada's Food Guide and the version for First Nations, Inuit and Métis are available online at www.healthcanada.gc.ca/foodguide. The guide includes more specific information based on your gender and age and gives examples of servings.

Keep in mind that food guides are developed for the population of the whole country. The recommendations don't take into account your special needs as a person living with HIV. And there may be other factors, like additional medical conditions, that may affect your diet. You can use the food guide as a good way to start building your balanced diet, but make sure you talk with your doctor and your dietitian about any special adjustments you may need to make.

Understanding Food

You're likely familiar with the terms carbohydrate, protein and fat. They are the building blocks of food. They are also the building blocks of our bodies -- they are used to create and maintain the physical structures of our bodies. Carbohydrates, protein and fat also provide energy for metabolism (the name for all of the normal chemical reactions that go on inside the body). We usually use the term calorie when talking about food energy.

Carbohydrates, protein and fat are called macronutrients because the body needs them in large amounts. Getting the right kinds and amounts of each macronutrient is critical to staying healthy.

Carbohydrates

Carbohydrates (carbs for short) are mainly used for energy. They fall into two groups, simple and complex.

Simple carbohydrates include sugars, fruits (especially juices) and white starchy foods such as white bread and white rice. These foods are digested easily and so are fast sources of energy. When you eat simple carbohydrates, the level of sugar in your blood goes up quickly but is held within a normal range by insulin (see "Insulin resistance and diabetes," Chapter 5).

Complex carbohydrates are a healthy source of energy.

Main sources of complex carbohydrates: whole grains, beans and peas, vegetables and fruits

Complex carbohydrates which include whole grains, legumes (beans and peas) and vegetables, raise the blood sugar levels more slowly and generally provide more fibre, vitamins and minerals than simple carbohydrates.

Carbohydrates are the most affordable foods and form the backbone of the diet. Generally speaking, complex carbohydrates are a better choice than simple carbohydrates. The body handles carbohydrates best when they are spread throughout the day, so you should try to include them in every meal.

Balancing Carbohydrates

Getting Started

  • Eat carbohydrates with every meal. They are affordable, nutritious and satisfying.
  • Eat some fruits and vegetables every single day.
  • Choose whole grain breads and cereals. Canada's Food Guide recommends that at least half of your grain products every day should be whole grain.

Other Tips

  • Choose more complex carbohydrates, like brown or wild rice, whole wheat bread and pasta, oatmeal, whole grain cereals, barley and vegetables.
  • Work up to eating 7 servings of fruits and vegetables daily. Frozen vegetables are a healthy alternative to fresh ones and keep longer.
  • Limit simple carbohydrates by reducing consumption of fruit juices, soft drinks and other sweetened drinks, desserts, candies and sugar.
  • Lower-cost carbohydrates include oatmeal, rice, bread, and fruits and vegetables in season. Small produce stands and farmers' markets sometimes offer lower prices for fruits and vegetables.

Proteins

Protein is especially important for people with HIV.

Main sources of protein: meats, fish and shellfish, poultry and eggs, legumes and soy products, nuts and seeds, milk and dairy products

Proteins have many important functions in every cell and system throughout the body. They are used to make cell structures, hormones, enzymes and components of the immune system. In general, people living with HIV need higher amounts of protein to maintain lean body mass and provide building blocks for the immune system. However, some medical conditions can be made worse by too much protein, so it is important to follow any directions your doctor gives you about your protein requirements.

Foods high in protein include meats, game, fish and shellfish, poultry, eggs, legumes (dried peas and beans), tofu, peanut and other nut butters, nuts and seeds, milk, cheese, yogurt and soy milk.

Aim for at least 1 gram of protein per kilogram body weight per day (1 gram per 2 pounds of body weight). See Appendix A for a list of good food sources of protein and Appendix B to figure out how much protein you need.

Boosting Protein

Getting Started

  • Find out which foods are rich in protein (see Appendix A) and then make sure you have them on hand.
  • Try to eat protein-rich foods at least 3 times a day.

Other Tips

  • Work protein-rich foods into every meal and snack. For example, a glass of milk or soy milk will add protein to a bedtime snack.
  • Powdered skim milk can be used to increase the protein content of foods and beverages.
  • Protein powders can be used to increase protein when you're finding it hard to get enough from your regular foods. Whey protein may be better for people with HIV because of its antioxidant-stimulating properties. It is possible to get too much protein from powders because they can be very concentrated. Too much protein places a lot of stress on the liver and kidneys -- the organs where protein is metabolized and excreted.
  • Lower-cost protein sources include peanut butter, tofu, legumes, canned fish, eggs and milk. Milk powder may seem expensive but it can go a long way and does not require refrigeration.
  • If you get paid once a month and you have a freezer, buying meat in bulk can be more economical. Package the meat into single portions and then freeze.

Fats

Fats and oils are the most concentrated source of energy in our food supply. Some fats are necessary in our diets to provide building blocks -- called essential fatty acids -- that the body can't make. However, eating too much fat is dangerous because it can clog the arteries and contribute to problems with your heart and blood vessels.

Healthy fats include monounsaturated fats and omega-3 fatty acids.

Examples of healthy fats: olive oil, canola oil, flax oil, nut oils, nuts, avocados

Some types of fats are more hazardous to our health because they increase the risk of heart disease. Saturated fat -- found in animal fats, dairy fat and palm oil -- should be limited to a very small amount. It is hard to completely avoid saturated fats because they occur naturally in many foods that are part of a healthy diet. Trans fats (or trans fatty acids) -- found in many processed foods -- are believed to significantly increase health risks and should be avoided. In Canada, laws require food labels to list the amount of trans fats in the food. Reading ingredient lists can also identify trans fats -- sometimes manufacturers use the term partially hydrogenated oil which is another name for trans fats. Processed snack foods like cookies, crackers and chips, as well as hard margarine and partially hydrogenated margarine are common sources of trans fats.

Healthy fats are composed more of monounsaturated fatty acids and omega-3 fatty acids. Examples of healthy oils and fats are olive oil, canola oil, flax oil, nut oils, nuts and avocados.

Eating Fat the Healthy Way

Getting Started

  • Learn to identify all the ways you get fat in your foods. Read labels and watch how you cook.
  • Choose lower-fat dairy products such as skim or 1% milk, low-fat yogurt, light cream cheese and lower-fat cheese (e.g. skim milk mozzarella).
  • Cut back on greasy, fatty foods, such as fried foods and fatty red meat.

Other Tips

  • If using margarine, use a type that is non-hydrogenated. If using butter, use sparingly.
  • Eat more fish, especially fatty fish like salmon, sardines, anchovies, herring and mackerel.
  • Use olive and canola oil for cooking.
  • Use lean cuts of meat and trim off visible fat. Remove the skin from chicken and other poultry either before or after cooking.
  • Baked goods and pastries are very high in fat (and not the good kind).
  • Learn to identify trans fats by reading labels; avoid products with "partially hydrogenated oil."

Don't Forget the Fluids

Your state of health can affect how much fluid you should drink. Check with your doctor.

Fluids are required to keep the body's cells working smoothly. Because we lose fluid through urine, stool and sweat, it needs to be replaced each day. An easy-to-remember rule of thumb is to drink 8 glasses of water a day. However, the amount of fluid you need depends on your body size and how much water you lose. If you want more detailed information about how much fluid you should be consuming, see Appendix B. Also bear in mind that other factors can play a role in how much fluid you need. For example, some medications require a high intake of fluids to protect the kidneys, while some medical conditions can be made worse by drinking too much water. Be sure to follow any directions given by your doctor about how much fluid to drink.

Drinking Enough Fluids

Getting Started

  • Get more of your fluids as water and less as sweet beverages (e.g. juice, drink crystals, soft drinks) and coffee.
  • If you don't like the taste of water, add one or two slices of fresh lemon or lime to a pitcher of water and store it in the fridge.

Other Tips

  • If you're not used to drinking much water, fill a bottle or jug with the required amount each day and do your best to drink all of it.
  • Drink small amounts often throughout the day. Fluids come in the form of water, juices, milk, soups, herbal teas and, according to some experts, even coffee and tea.
  • Alcohol does not count in fluid intake because it removes water from your body.
  • Keep water at your bedside for drinking during the night.

Meal Planning

Before looking at how to build a diet, a menu or even a meal using the fundamentals of good nutrition, stop for a second and think about this: You've gotten this far in life, so you must be doing some things right when it comes to food. But there is always room to do better. If you really want to know how you're doing, here's something to try: For three days, write down everything you eat and drink. Try to include one weekend day in your three days. This should give you a general idea of your eating habits right now.

When changing your eating habits, start with one thing at a time.

There's no way around it: Changing your eating habits is hard work. But don't think of changing everything at once. Start with one thing. When you succeed, feel good. When you slip, don't feel bad. The advantage of nutrition is that you always have a chance to do it better at the next meal or snack.

One of the keys to eating well is to make sure you have healthy food available when you're hungry. This can range from throwing an apple or some nuts in your bag for a quick, easy snack to planning a menu for several days. Healthy eating does require some thoughtfulness and preparation, including planning meals and purchasing the required groceries. There will be more of this kind of work in the beginning as you learn what works for you. As you become more knowledgeable, it will likely become easier. It might even become second nature.

Stocking a Healthy Pantry

Getting Started

  • Identify the things you need to do to eat more healthfully (e.g. replace your afternoon chocolate bar with a banana, your late-night bag of chips with some almonds and a glass of soy milk).
  • Start with small steps and try to change only one thing at a time.

Other Tips

  • Plan ahead. Start with planning the main meal of the day for the next 2 or 3 days. Work up to making a weekly menu. Make a list of the groceries you'll need.
  • Bring the list to the grocery store and have a snack before you go. Both will help keep you from making impulse purchases.
  • Don't purchase large packages of unhealthy foods that you can't resist (e.g. the econo-bag of potato chips that always seems like a bargain).
  • Read the nutrition information and ingredients on food packaging. Your dietitian can help you learn how to interpret the information.
  • Focus on more unprocessed foods and whole grains. Over time, you might find you skip the grocery aisles filled with processed foods.
  • Think about brushing up on your cooking skills. Crack open a recipe book and start with the basics. Simple foods from natural ingredients are not only healthier and easier to cook, they are often cheaper.
  • Carry healthy snacks. This will decrease the likelihood of needing fast food or junk food to curb sudden hunger.
  • If you get paid once a month, stock up on foods like oats, peanut butter, canned fish, brown rice, pasta, canned lentils, black beans, baked beans, pea soup and frozen vegetables.
  • No fridge or stove? There are many foods that are nutritious, keep well and don't require a lot of cooking, including:
  • bread or bagels
  • peanut butter and nuts
  • cereal and granola bars
  • powdered milk
  • canned salmon, sardines and tuna
  • canned beans, vegetables and fruit
  • rice cakes and crackers
  • raisins, bananas and apples
  • nutrition drinks
  • Find out about and use food programs in your neighbourhood.
  • Join a community kitchen if there is one nearby. This is a good way to learn how to cook and save money on meals by sharing the cost. They also make meals more social, an important benefit of good nutrition.
  • Read "KISS in the Kitchen -- 15 food groups to pack in your pantry" in the Spring/Summer 2004 issue of CATIE's The Positive Side, available at www.positiveside.ca. And don't forget to check out the Web resources listed in Appendix D for other ideas.

Planning a Menu

Try to eat a wide variety of foods to get the nutrients you need.

One way to build a menu is to arrange your daily servings of the different food groups into a series of meals and snacks. Below we've outlined a five-step path to building a daily menu that includes five meals or snacks. It might seem counter-intuitive to build a menu up from components, but it's a good way to ensure you're getting what you need.

Planning a Menu: 5 Steps to Getting Started

1. Start With Fruits and Vegetables (7 Servings)

  • There are many healthy foods to choose from in this category. The serving sizes are quite small (about ½ cup) so you might choose 2 servings of the same food (e.g. 1 cup of cooked carrots).
  • If you currently eat 1 serving per day, try to add a few more servings even if you don't get up to 7. Spread out the fruits and vegetables throughout your meals and snacks.
  • Make sure you eat both vegetables and fruits throughout the day, not just one or the other.
  • Include fresh, frozen, canned or dried vegetables and fruits as well as vegetable or real fruit juice. Eat more whole fruit and drink less juice.
  • Look for colours, lots of different colours. Try to include 1 dark green (e.g. broccoli, spinach, kale) and 1 orange (e.g. carrot, squash, sweet potato, pepper) vegetable.
  • Some people with HIV may not be able to tolerate this many servings of fruits and vegetables because of the high fibre content. Eat what you can. (See "Figuring out fibre," Chapter 6.)

2. Then add grains (6 servings for women, 8 for men)

  • Spread out the servings throughout your meals. For example, you might want to have 2 servings at breakfast, lunch and dinner. Extras can be added as snacks.
  • Include foods such as bread or bagels, pasta, hot and cold cereals, rice, barley, quinoa and couscous.
  • Make most of your choices whole grain (e.g. whole wheat, oat, flax, millet, buckwheat, spelt and brown or wild rice).

3. Combine with milk products and alternatives (2-3 servings)

  • Include cow's or goat's milk, cheese, yogurt, kefir and milk alternatives (such as soy, almond or rice milk).
  • If you need extra protein or calories or you have osteopenia, you might need more than 3 servings. (See "Bone health," Chapter 5.)
  • When choosing a milk alternative make sure it is fortified with calcium and vitamin D.

4. Serve with meat and alternatives (2-3 servings)

  • Include food from animals, such as meats, fish, poultry and eggs, as well as legumes (dried peas, lentils and beans) tofu, peanut butter, nuts and seeds. (See Appendix A for serving sizes.)
  • Choose 3 or more servings if you need extra protein.
  • Choose lower-fat products and cook with little added fat.

5. Sprinkle lightly with fats and oils

  • Aim for about 2-3 tablespoons of added fats daily. This includes butter, oil, salad dressing, margarine and mayonnaise.

A Sample Food Plan for One Day


 

Fruits and Vegetables

Grains

Milk and Alternatives

Meat and Alternatives

Fats and Oils

Breakfast

 

 

 

 

 

½ cup berries

1

 

 

 

 

1 cup bran flakes

 

1

 

 

 

1 cup milk

 

 

1

 

 

Lunch

 

 

 

 

 

1 cup vegetable soup

1

 

 

 

 

1 cup green salad

1

 

 

 

 

Salad dressing

 

 

 

 

1 tbsp

Chicken breast sandwich

 

2

 

1

1 tbsp

Afternoon snack

 

 

 

 

 

Apple

1

 

 

 

 

1 container yogurt (175 g)

 

 

1

 

 

Dinner

 

 

 

 

 

½ cup cooked carrots

1

 

 

 

 

½ cup cooked broccoli

1

 

 

 

 

1 cup brown rice

 

2

 

 

 

Grilled fish

 

 

 

1

 

Evening snack (good with meds)

 

 

 

 

 

Banana

1

 

 

 

 

1 small whole grain bagel

 

2

 

 

 

Cheese (increase or decrease fat depending on meds)

 

 

1

 

2 tbsp

Total

7

7

3

2

4 tbsp

This menu provides approximately 2,200 to 2,400 calories and 85 to 90 grams of protein.


In this plan, we haven't worried too much about the total number of calories you are eating. By following the recommended servings of Canada's Food Guide and by listening to your body, you will likely have a good idea of how much food is enough. If you want more information, see Appendix B for recommended caloric intake by body weight.

If you are trying to gain or lose weight, counting calories is a useful tool. You'll most likely want to know how many calories to add or cut out rather than total numbers required. See Chapter 3 for further discussion on calories and weight.

A Meal Is More Than Just Food

There's a lot more to a meal than just the food. There is a whole emotional and social context that comes with food. Sometimes we use food to celebrate, sometimes to console. And we often use it as a way to spend time with other people. When thinking about meal planning, don't forget this important aspect of food. And try to use it to make your life better. That could mean sharing a meal with friends or family, or taking pleasure in the fact that you created the meal yourself. Living with HIV poses many challenges and taking charge of your nutrition can be a positive, enriching experience.

Different Diets

Whatever diet you follow, make sure it meets your nutritional needs as a person with HIV.

There are many factors that can affect your diet: medical conditions, religious beliefs, cultural practices or ethical concerns. There are so many variations that we can't address them all here. Instead, try to get advice from someone, like a dietitian or doctor, who has experience with people in your situation.

Vegetarian Diets

Many people choose to avoid animal foods for health, religious or ethical reasons. There are many different kinds of vegetarian diets, from strict forms like vegan and macrobiotic to more relaxed diets that include some animal products (e.g. eggs and dairy).

Vegetarian diets are generally very healthy because they are high in whole grains, fruits and vegetables. However, for people living with HIV, it may be more difficult to obtain enough protein. Those who consume eggs and dairy products find it easier to get adequate protein by including these foods regularly, but vegans who avoid all animal products need to be more aware of protein intake and ensure that they get enough. It is important to include vegetarian sources of protein, such as soy products, legumes, gluten, nuts and seeds, at each meal and snack.

Other nutrients you might not get enough of are iron, zinc, vitamin B12, calcium and essential fatty acids. To be sure you are meeting all your nutritional needs, get advice from a dietitian.

Meeting Your Needs Without Eating Meat

  • Focus on protein-rich foods. Include vegetarian sources of protein with every meal and snack.
  • Eat a wide variety of foods to get all the building blocks needed to make the body's protein.
  • Get plenty of iron from greens, whole grain cereals and legumes.Iron is absorbed better if you eat food high in vitamin C (e.g. oranges, red peppers) at the same time.
  • If you are vegan and eat no food from animals, you should talk to your doctor about whether you need to watch the levels of vitamin B12 in your blood (see "Key vitamins and minerals for HIV," Chapter 4).

Diets of Different Cultures

In Canada, people with HIV come from diverse cultural backgrounds and have diverse diets. People often mix their culture's eating habits with the typical North American diet or with food from other cultures. This can be a great advantage because it allows people to benefit from the nutritional strengths of each culture's diet. For example, African diets include foods that are good sources of complex carbohydrates. Traditional diets of Canada's Aboriginal people tend to be rich in protein from fish and game and can be high in antioxidants if locally available fruits, berries and greens are eaten regularly. Asian and South Asian diets incorporate ideas of foods that can heal, which can be valuable when dealing with side effects of medication.

Whatever diet you follow, the most important thing is to make sure it meets the basic nutritional needs of people with HIV.

  • Pay attention to your weight and make sure you're getting enough calories to maintain your weight. Choose complex carbohydrates as a main source of calories.
  • Get enough protein. In Canada, good sources of protein are readily available and relatively affordable.
  • Watch out for deficiencies in vitamins and minerals (see Chapter 4). Every person with HIV would benefit from taking a multivitamin-mineral supplement every day.
  • Incorporate your strategies for managing common side effects and symptoms into your nutrition plan. If you decide to take an herbal therapy, be sure to tell your doctor and pharmacist, so they can make sure it will not interact with any medications you're taking.

Food and Water Safety

Food Hygiene and Sanitation

When preparing food remember the motto "be clean".

People with weakened immune systems are more vulnerable to illness from food that has become contaminated by disease-causing germs. Often called "food poisoning," the symptoms include nausea, vomiting, chills, cramps and diarrhea. They can be short-lived or can become chronic and difficult to treat, especially for people with HIV. Common types of bacterial infections are salmonella, campylobacter, listeria and E coli. Other harmful substances can sometimes be found in food, like moulds and industrial toxins such as PCBs and mercury.

You usually have little control over food production, transportation, processing and storage, but you do have control over how you select your food and handle it at home.

Keeping Your Food Safe

  • When buying food, avoid damaged cans and packages. Buy only pasteurized milk, cheese, honey, apple cider and fruit juices. Check the "best before" date. Avoid alfalfa sprouts, cracked eggs and bruised or mouldy fruits and vegetables. Buy cold and frozen foods last when shopping and go directly home to refrigerate or freeze them.
  • When storing food, keep perishable items in the fridge and keep meats on the bottom shelf. Don't reuse plastic bags for food storage. If foods have become mouldy (e.g. cheese) discard them because mould has invisible roots penetrating the food.
  • Food preparation is one area where many people have acquired unsanitary habits. "Be clean" is the motto of food preparation: clean hands, clean work surfaces, clean utensils and clean foods. Wash your hands with warm, soapy water. Wash fruits and vegetables under running water. Thaw frozen foods in the fridge, not at room temperature. Avoid contamination by keeping raw meats, their juices and packaging away from other foods. After preparing raw meats, clean the preparation area and all the equipment and cutting boards with hot, soapy water. To be sure, you could also rinse with a weak bleach solution (1 teaspoon of bleach in 1 litre of water)
  • When cooking, make sure all food from animals (including meats, poultry, fish and eggs) is well done. Always keep hot food hot and cold food cold. Hot dogs should be cooked steaming hot. Cut the green part off potatoes and eat the white part inside. Don't eat uncooked cookie dough or cake batter because of the potential of salmonella in the raw eggs.
  • Leftovers are safe and practical to eat if handled properly. Store leftovers in the fridge or freezer right away. If it is a large amount of hot food, place it in a container and sit the container into a large bowl of ice water to cool it down before refrigerating. Eat leftovers within 2 to 3 days; label them with the date so you know how long they have been in the fridge. Reheat leftovers to steaming hot. When in doubt, throw it out because contaminated food does not always look or smell bad.
  • When eating out, choose restaurants that are clean and appear to have a high standard of food sanitation. Eat cooked foods like well-done poultry, meat, shellfish and eggs. Hot foods should come to the table hot. Avoid salad bars, sandwich bars and juice bars. Some foods, like Caesar salad, gazpacho and mousse, may contain raw eggs. Sushi made with vegetables and cooked seafood is safer than sushi made with raw seafood. Take leftovers home and refrigerate immediately.
  • When travelling, think even more about the safety of the food you eat and the water you drink. Some places you visit might not have clean water or safe food-handling practices. (For more information, see "Vacationing with the Virus," in the Spring/Summer 2006 issue of CATIE's The Positive Side, available at www.positiveside.ca.)
  • Reduce exposure to contaminants like mercury and PCBs by eating a wide variety of foods and limiting food known to have high levels of specific toxins. Tuna, for example, is theoretically a healthy food but should be limited to about 2 to 3 servings per week because of high mercury levels. Pregnant women and young children are particularly vulnerable to the ill effects of mercury.

Water Safety

Normally the water supply in Canadian cities and towns is safe to drink because chlorination kills most of the germs that cause infection and diarrhea. Cryptosporidium is one germ that is not killed by chlorine, but it is not usually found at high enough levels to cause problems. If Cryptosporidium levels increase to a dangerous level, a public health warning is issued.

Use purified water if your CD4+ count is below 200 or if your water supply is not treated.

People with low immune function -- especially with a CD4+ count of less than 200 -- are at increased risk of getting infected by Cryptosporidium and may need to take special precautions (see below). People who obtain water from wells or other sources of untreated water should also follow these guidelines even if they have a high CD4+ count. If there is a water advisory, it also may be necessary to use treated water to wash foods and brush your teeth.

Treating Your Water Right

Use one of the following three methods:

  • Boil tap water for 1 minute at a rolling boil. Boil water once a day and keep it in the refrigerator. Boiled water should be used for drinking water, ice cubes and making juice, coffee or tea.
  • Filter the water with filters that remove all particles that are 1 micron in size or larger. Some commercial filters are not small enough. Make sure the filter you are using is the right size. For example, the Brita filter for the pitcher is not the right size but the Brita filter for the tap is.
  • Use bottled water that has been distilled or treated by reverse osmosis. Not all bottled water has been treated, especially the water sold in individual-size bottles. Water coolers and other containers for bottled water can be a major site of microbial growth. Bacteria and moulds grow in these containers; they must be thoroughly cleaned inside with a vinegar solution at least once a month. Don't reuse individual-size water bottles. They can harbour bacteria and moulds.

What's Different for People With HIV

Most of these guidelines apply to everyone but they are especially important for people with lower CD4+ counts. People with HIV with a CD4+ count less than 200 have the highest risk of getting sick from food or water contamination and should follow these guidelines carefully.





  
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