Malnutrition is a general term describing improper nutrition, either in excess or deficiency. Some examples include protein and/or calorie deficiency, micronutrient deficiency and overnutrition resulting in obesity.1 Manifestations of malnutrition vary globally. In resource-poor areas described in this paper, it manifests as kwashiorkor (protein malnutrition), and marasmus (protein and calorie malnutrition), or the deficiency of specific nutrients. In New York City, a resource-adequate setting, the majority of malnutrition takes the form of obesity, with possible deficits in micronutrients due to consumption of food available in low-income communities.
While malnutrition is exhibited differently depending on location, food insecurity is present everywhere. We define food insecurity as the lack of regular access to ample quantity and quality of safe, nutritious food that meets dietary needs as well as food preferences of individuals and communities.
This article examines the effects of malnutrition and food insecurity in the global HIV/AIDS community, and proposes possible solutions to decreasing global malnutrition and food insecurity.
There is a large body of evidence that supports that inappropriate food intake negatively impacts immune function.2,3 Deficits in certain micronutrients such as vitamin A,4 vitamin C,5 vitamin D,6-9 zinc,10 selenium,11,12 copper,13,14 and iron15,16 impair immune function. A high content of dietary fatty acids, specifically saturated fat, plays a role in immune suppression.17 Protein deprivation decreases many body functions including the production of inflammatory mediators that are needed to fight infection.18,19
Studies completed before and after the advent of Highly Active Antiretroviral Therapy (HAART)20 show that wasting (a form of malnutrition) is a predictor of death for HIV-positive individuals.21-24 A groundbreaking 2006 study done in 2006 found that moderate to severely malnourished people starting HAART experienced a six-fold higher hazard ratio for death. Those starting Antiretroviral Therapy (ART)25 who were moderately to severely malnourished were twice as likely to die as those who were not malnourished. Malnutrition decreases survival in patients starting ART and HAART for several possible reasons: impairment of immune reconstitution and in turn a prolonged period of opportunistic infection risk; adverse effects on drug absorption; lower threshold for drug toxicity; and/or decreased physical function.26
Food insecurity plays a major role in the development of malnutrition in resource-poor and resource-adequate settings. In resource-poor settings, there is decreased or no adult labor in HIV/AIDS affected households. These households have less capacity to produce or purchase foods and have higher medical costs. In addition, children often stop their schooling to work, or simply because the family affected by HIV can no longer afford the education. Research in Tanzania showed that food consumption decreased 15 percent per capita when an adult died. Funeral costs deplete monies that could be used for food. The agricultural knowledge base of families and communities decreases as individuals with farming and science knowledge die from HIV/AIDS.27
Women are especially vulnerable in HIV/AIDS-affected households. Usually, they care for the sick and dying in addition to maintaining heavy workloads related to gathering food and feeding the household. If the mother dies of HIV, often the family goes hungry because of decreased means of food gathering and preparation. One study showed that food insecurity and malnutrition were the most immediate problems faced by female-headed households affected by HIV/AIDS in Uganda.28
Our work with hundreds of clients in New York City has demonstrated many similarities among our food insecure population. Food assistance programs are not geared towards people living with HIV/AIDS who have increased nutritional needs. In addition, there are few supermarkets or places that offer fresh, whole foods in low-income neighborhoods. Markets that do carry these types of foods tend to be very expensive. This makes it difficult for HIV-positive individuals to obtain nutritious foods through food stamps and other supplemental subsidies.
Due to the lack of nutritious foods accessible to low-income HIV-positive individuals, many eat foods that contain a high amount of refined carbohydrates, saturated and trans-fats, and calories with little micronutrient value. Because of this we see many obese clients with diseases characteristic of the general obese population.
Food insecurity in itself is a risk factor for HIV/AIDS transmission. Malnutrition has been shown to increase transmission of HIV from a pregnant woman to her fetus, which remains a major issue in the developing world.29 In addition, because of food insecurity and decreased access to safe water supplies, HIV-positive mothers are forced to breastfeed their children, which further increases the risk of HIV transmission.30
In addition to mother to child transmission, food insufficiency is associated with increased HIV risk-taking behavior and sex exchange. A recent study of food security and HIV risk behaviors interviewed 2,051 adults in Botswana and Swaziland. The individuals were asked information about their food intake over the previous 12 months. Condom use, sex exchange, and other HIV risk-taking behaviors were examined. For women, sex exchange was defined as exchanging sex for food, money or other resources; for men, sex exchange was defined by paying for or providing resources for sex. HIV risk behaviors included inconsistent condom use, intergenerational sex and lack of control over sexual relationships. Of all study participants, 32% of women and 22% of men experienced food insufficiency in the previous 12 months. This study sends a clear message that without adequate food, individuals may surrender long-term health and safety to survive in the present.31
A program in the Democratic Republic of Congo (DRC) demonstrates that when multiple institutions work together, societies can successfully diminish malnutrition and food insecurity. Bukavu, like other cities in the DRC and around the globe, suffers continual conflict and humanitarian crises. Many structures -- including society, economy, and health care system -- are near collapse. Because of the lack of infrastructure, and security, deploying effective social programs is difficult. However, in 2003, Médicins Sans Frontières (Doctors Without Borders) worked with the Food and Agriculture Organization of the United Nations and the World Food Programme of the UN to create a food security program for HIV-positive individuals in Bukavu. This included distribution of seeds, tools and agricultural support, as well as a nutrition support system which distributed food rations and nutrition education to over 200 families. This program improved the medical management of HIV, as demonstrated by overall weight gain. If many more medical and nutrition agencies collaborated together, using Bukavu as an example, there would be more success in overcoming the challenges of food insecurity, malnutrition and HIV.32
Clearly there is overwhelming evidence that confronting malnutrition and food security in the HIV/AIDS community is necessary to successfully treat the disease. It is imperative that in addition to increasing access to HIV medications, organizations must also provide nutritious, safe and sustainable food assistance.
Sarah Spool M.S., R.D., C.D.E., C.D.N. is the Assistant Director of Nutrition Education and Health Outcomes at Gay Men's Health Crisis (GMHC). Jenny Torino M.S., R.D. is an HIV Nutrition Specialist at GMHC.
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