Diet and Nutrition for People Living With HIV

HIV has become a manageable chronic condition. As a result, developing healthier diet and nutrition practices can augment a person’s overall health.

Nutrition is one of four facets of a person’s well-being, says Jamie Garry, M.S., RD, LDN, senior clinical research dietitian at Massachusetts General Hospital. These four “quadrants of health” are getting enough sleep, exercising, eating well, and taking care of our mental health. Making strides in these areas can help everyone—not just people living with HIV—stave off illness and experience a better quality of life.

Researchers continue to learn more about the connections between these quadrants, says Garry. It makes sense that eating well and exercising can help us sleep better. But other links might not be as obvious. For example, the gut’s microbiome can affect a person’s serotonin level, says Garry, which in turn affects mental health.

“So I think it’s important to fuel your body the right way,” says Garry.

Rachel Kleinman, M.S., RD, LD, CDCES, a registered dietitian for Food Outreach, a nonprofit that provides nutrition support to people living with HIV and cancer, says that good nutrition helps support immune-system function. Some nutrients from food help produce white blood cells, antibodies, and even antioxidants that protect cells.

Good nutrition is important for everyone, but particularly for people living with chronic illnesses like HIV, says Garry. The resulting inflammation leaves people more vulnerable to other medical conditions like diabetes or cardiovascular disease. Having a healthy diet can set a person’s body up for success and reduce the chances of developing other health problems.

Benefits of good nutrition include:

• Having more energy.

• Feeling better.

• Improving mental health.

• Reducing the chances of developing other health conditions.

• Raising your quality of life.

If you’re eating a lot of junk, you may feel lethargic and less able to do tasks you want or need to get done. Ultimately, Garry says that eating healthier allows people to feel better, be more active, and do the things they love, whether that be work, hobbies, or anything else.

While good nutrition is important, taking antiretrovirals as directed by a doctor is the most critical thing a person with HIV can do to increase their overall health. Despite what anyone says on the internet or elsewhere, there are no foods or supplements that cure HIV. There’s also not a particular “best” food for people with HIV or “best” fruit or vegetable people with HIV should eat more of.

Instead of finding “silver bullets,” which don’t exist, Garry advises her nutrition clients to aim for the following four main goals:

• Drink plenty of water (about 2 liters per day).

• Eat lots of plants.

• Focus on whole foods.

• Use heart-healthy fats, such as vegetable oils.

But nutrition is highly individualized, says Garry, adding that not everyone can afford or tolerate certain foods. Furthermore, not everyone likes the same foods, so there isn’t one way that everyone should eat. Nonetheless, she says that people can benefit from incorporating certain items in their diet, such as:

• Fruits and vegetables: “I like the idea of eating the rainbow—get the different colors of fruits and vegetables because each color usually signifies a different nutrient,” Garry says. Orange items, like carrots, are high in vitamin A, for example, and blue produce tends to contain antioxidants that can help counteract cell damage. Dark leafy vegetables like broccoli, Swiss chard, kale, and spinach are low in calories, high in fiber, and a good source of minerals like potassium and magnesium.

• Fatty fish: Fatty fish like salmon, mackerel, and tuna are not only a great source of protein, Garry says they also provide omega-3 fatty acids, which help cells function and may lower the risk of cardiovascular disease.

• Seeds: If you’re allergic to fish or don’t like it, she says that seeds—including chia, flax, hemp, pumpkin, or sunflower seeds—are another source of omega-3s.

• Nuts: All kinds of nuts contain heart-healthy fats as well as some fiber and protein. Garry notes that nuts can also have a lot of calories. So if a person’s goal is to lose weight, she advises, “just be mindful of how much [you’re] having.”

• Fermented foods: Fermented foods such as yogurt, kefir, kimchi, and sauerkraut all have good bacteria to promote gut health.

• Beans: Beans are high in protein and fiber, but low in fat.

Dietary Guidelines for Americans, 2020-2025, contains additional recommendations for building healthier routines around food.

Aiming for these goals doesn’t mean achieving perfection. Garry points out that eating should also be fun and enjoyable. Many people eat to be social, so we shouldn’t neglect other important aspects of consuming food.

“There’s nothing that you can never eat. And I think it’s all about balance,” she says. She recommends people shoot for healthy eating about 80% of the time, and indulge the other 20%.

The worst foods, she says, are highly processed or contain lots of chemicals. For example, neither diet nor regular sodas provide any nutrients. “They’re all just kind of garbage,” she says but reiterates that having one every now and again is fine. Garry also recommends avoiding candy, especially candies with artificial dyes and other chemicals.

The Dietary Guidelines for Americans also recommend cutting down on foods with added sugar, added sodium, and saturated fats. The guidelines suggest strategies such as:

• Swapping out soda for sparkling water or unsweetened tea. (However, be mindful of flavored sparkling water, which may contain added sugar; check the ingredient list and nutritional information on the package.)

• Eating plain oatmeal or yogurt instead of sugary cereals.

• Cooking more meals at home rather than purchasing pre-made sandwiches, burgers, tacos, rice dishes, soups, and pizza—all of which may have a lot of sodium (as well as saturated fats).

Similar to Garry’s suggestion to aim for an 80%-to-20% balance, Taylor Aarns, M.S., RD, LD, also a registered dietitian at Food Outreach, says that a perfect diet is not the goal. “I would just recommend starting with reviewing some of your favorite meals and seeing where you can add to that,” she says. For example, if pizza is something you enjoy eating, try adding spinach or another vegetable to it to increase the amount of nutrients you get from eating it.

Aarns says that this method of adding to what you’re currently eating is “a bit more manageable versus thinking that you have to overhaul your diet.” If you’re not eating fruits and vegetables, she advises finding a way to add one portion a day to one of your preferred meals and building from that.

In general, all three dietitians that TheBody spoke with say that food is the best source of nutrients. Supplements usually aren’t required unless someone has a confirmed nutrient deficiency measured with blood tests at a medical clinic.

While Garry says that most supplements won’t harm someone, she recommends discussing them with your doctor or pharmacist before trying them. A few foods and supplements have been found to interact with antiretroviral therapy (ART) and should be avoided. Dan Scales, Pharm.D., AAHIVP, Vivent Health’s director of clinical pharmacy, writes via email that when something is “contra-indicated” for people taking ART, they should avoid taking it. According to data collected so far, these include:

• St. John’s wort (Hypericum perforatum) should be avoided with most, if not all, forms of ART. Newer drugs have theoretical interactions but have not yet been tested.

• Red rice yeast (Monascus purpureus) should be avoided with protease inhibitors and at least one integrase inhibitor, and used with caution with older ART formulations like efavirenz and nevirapine.

Other interactions may not be as severe and are labeled as “use with caution.” Each of the following interact with different drugs, so check with your doctor if you’re taking any:

• Grapefruit

• Ginkgo (Ginkgo biloba) should be avoided specifically when taking efavirenz, a medication that is rarely prescribed today.

• Bitter orange (Citrus aurantium)

• Borage (Borago officinalis)

• Garlic (Allium sativum)

• Sweet orange (Citrus sinensis)

“The biggest [thing] for patients to know is to communicate what they are taking to their care team,” says Scales. That's because the above lists are based on the most recent published studies but may not reflect ongoing trials.

Though ART formulations have become more tolerable over time, some people still experience side effects such as a lack of appetite, nausea, diarrhea, and weight gain.

Garry says that dealing with these side effects is another reason why nutrition isn’t black and white. If people feel nauseous, they should eat whatever they can tolerate, including processed foods like crackers.

For nausea, vomiting, or a lack of appetite, eating smaller, more frequent meals can help. “So instead of having your regular breakfast, lunch, dinner, you might [have] mini-meals or snacks throughout the day,” she says. In addition, eating blander foods can help. If tolerable, drinking liquids such as juices or smoothies can be a good way to get calories.

In the case of vomiting and diarrhea, trying your best to drink water and other fluids to stay hydrated is important. If you’re in the throes of acute diarrhea, then Garry recommends the BRAT (bananas, rice, applesauce, and toast) diet.

Aarns says that poor appetite comes up with many of her clients. “If your body’s not telling you you’re hungry, you’re often going long periods of time without eating,” she says. As a reminder to eat, she recommends pairing food with an activity. For example, if someone listens to music at a certain time each day, they can try to incorporate having a snack at that time.

In the beginning of the HIV epidemic, with less effective ART regimens, many people expressed concerns about how to gain weight with HIV. Today, losing weight has become more of an issue with modern ART formulations. Garry says that most of her patients who want to lose weight aren’t drinking enough water. “We tend to confuse our hunger and thirst cues,” she says, so some people might eat more when they’re actually thirsty.

Another weight-loss strategy she recommends is to monitor portion sizes, potentially using one of a variety of phone apps available. “Tracking your intake can really give you a sense of what you’re actually eating.”

Garry also recommends a weekly self-check for people trying to lose weight. She says that rating your food intake—without judging or criticizing yourself—on a scale of 1 to 10 and then thinking about what influenced that rating can help. If someone rates their week as a 6 one week because they ate more than they planned, then it can be helpful to think about strategies to improve to a 7 over the next week.

Garry says not to forget about the other three quadrants of health because sleeping well, good mental health, and staying active can also help you lose weight.

Another consideration of diet is food safety. Kleinman says that even when HIV is fully suppressed with ART, people living with the virus are more susceptible to foodborne illnesses. Garry adds that food safety is also more important for pregnant people, kids under five, elderly people, and people who have other chronic illnesses. To protect yourself, Kleinman and Garry recommend:

• Washing hands frequently when cooking and before eating.

• When cutting meat, keeping knives and cutting boards separate from those used to prepare other foods.

• After transporting raw meat to a grill or oven, using fresh plates to retrieve the meat when it’s finished cooking.

• Cooking food to appropriate temperatures (145°F for beef and pork and 165°F for chicken).

• Keeping refrigerated food cooler than 40°F.

• Eating food that’s taken out of the refrigerator in less than two hours.

Here are 11 takeaways about HIV and nutrition:

• Eating a healthy diet, getting enough sleep, exercising, and taking care of our mental health are all ways to improve overall well-being and quality of life.

• Good nutrition isn’t black and white. It’s individualized. Allergies, the amount of money we earn, whether we have stable housing, suffering from medication side effects, and a wide variety of other factors can influence our ability to eat healthily.

• Good nutrition also doesn’t mean eating perfectly all the time. Striving to eat healthy 80% of the time and indulging the other 20% is a great goal.

• If you’re wanting to improve your nutrition, you don’t have to overhaul your entire diet all at once. Adding healthy ingredients to your favorite meals can be a way to make incremental changes.

• Four things that can strengthen your nutrition include: drinking enough water, eating lots of plants, eating whole foods, and cooking with heart-healthy fats like vegetable oils.

• If possible, reduce your consumption of highly processed foods, food and beverages with added sugar, food and candy with a lot of chemical ingredients, and food with a lot of sodium and saturated fats.

• The best way to get nutrients is through eating a variety of foods. Supplements should generally only be taken when a doctor confirms you have a nutrient deficiency.

• If you do decide to take a supplement, check with your doctor or pharmacist first in case it may interact with your ART.

• Avoid taking St. John’s wort and red rice yeast because of known interactions with HIV medications, and consider reducing consumption of grapefruit.

• Talk to your doctor or seek the help of a nutritionist if you’re experiencing side effects from your ART that impact your ability to eat healthily.

• To minimize the chance of getting foodborne infections, use good food safety practices like washing your hands frequently when cooking.