Highlights from the XVII International Conference on HIV/AIDS held in
Mexico City, Mexico, August 3-8, 2008
George M. Carter
[For the New York Buyers’ Club]
This review focuses on nutrition and CAM presented at the conference, along with some other selected issues. Clearly, it is a very big conference and a lot of issues were covered. Some of the sites that provided excellent reviews are provided at the end of this article. In addition, the Kaiser Network and the Conference site itself have many of the sessions available for viewing online and/or as transcripts.
NYBC’s sister organization, the Foundation for Integrative AIDS Research (FIAR – www.fiar.us) was pleased to have an abstract accepted by the conference (published below) along with their partners at Mount Sinai Medical Center, New York, NY. The study was 52-week, double-blind, randomized study of milk thistle among individuals co-infected with HIV and hepatitis C (HCV). The best news was that no effect was seen on HIV load, indicating that the milk thistle did not have a deleterious impact on blood drug levels (despite some in the community erroneously claiming a significant risk).
The role of nutrition was covered in a session that addressed food insecurity (a term I find clunky and inadequate) and the risks presented by it. Since there appears to be no other reporting on this session, I shall review it here. You may read the entire transcript here: http://www.aids2008.org/Pag/PSession.aspx?s=44. While the focus is primarily on developing nations, hunger is common in the United States. Obesity reflects the problem for many to access nutritious foods, in favor too often of processed foods, high fructose corn syrup in soft drinks and other foods and fast foods: cheap, lousy food that only adds to the troubles faced by those also living with HIV. And indeed, that food is often MORE expensive in poor, urban areas. See http://www.physorg.com/printnews.php?newsid=138629373.
The session’s name and abstract:
THBS02 Food Security, Nutrition and HIV: Bridging Session
Time: Thursday 7 August
Chair: Alan Whiteside, South Africa
The move towards Universal Access has highlighted a number of emerging issues related to food security and nutrition in resource poor settings. Although there is a growing consensus concerning the need for food, including clean water, and nutritional support to accompany ART, home-based care programmes and programmes for children affected by AIDS, experiences to date have highlighted a number of issues surrounding how to actually best deliver food and nutritional support. This session will address why food and nutrition are important, what are lessons learned from the field, how countries have incorporated nutrition into national AIDS policy and action plans and what the cost/benefit is of having nutrition and food activities in a variety of AIDS programmes. THBS0201
Perhaps the most affecting presentation was given by a clinical nutritionist from Kenya, Lucy Chesire. Dr. Chescire is also an African woman living with HIV. She highlighted the many issues confronting individuals living with HIV for whom access to food can be problematic at best. Lack of food compels some to either skip medications (for fear their returning appetite could not be assuaged) or even sell their drugs for food. Chronically malnourished individuals also suffer an increased risk and more dire outcome from commonplace and opportunistic infections. (For example, one study noted a significant recurrence of turberculosis among those receiving micronutrient supplementation including selenium and vitamins A, B complex, C, and E, while on TB treatment; see http://eatg.org/news/newsitem.php?id=15111.)
HIV also directly has multiple effects, being an infection that primarily affects the gut, damaging its function from the very earliest stages of disease. As Dr. Chescire notes, HIV disease has clinical outcomes that may include weight loss, progressive muscle wasting, reduced immune competence, hair changes, diarrhea and poor absorption. Together, these result in the well-established reduction in the blood levels of many micronutrients (vitamins, minerals such as vitamins A (carotenoids), B12, C, E, other B vitamins, selenium, zinc). In addition, HIV infection engenders inflammatory processes that damage healthy cells and tissues as well as increase energy needs (and thus the even more critical need for adequate caloric intake).
Indeed, Nigel Rollins, a pediatrician, pointed out at this session that a WHO report underscored that individuals with HIV and adequate food consumption require approximately 10% more caloric energy than non-infected individuals. As he notes, [w]hen you have an opportunistic infection like TB or chronic lung disease or diarrhea or some of the malignancies, that energy expenditure increases by about 25 to 30 percent. And when you are severely malnourished, up to 100 percent, especially in a small child.
Clearly, access to food and clean water remains essential and represents a serious challenge for literally billions of men, women and children. Rollins notes that the UN Development Program reports that globally, more than 1.1 billion people worldwide do not have access to clean water. 2.6 billion do not have adequate sanitation. And diarrhea due to lack of clean water kills five times as many children as HIV. To my utter frustration and despite current evidence of the benefits of “even mega” doses found in a simple multivitamin, he claims the evidence remains “inadequate” to begin programmatic activity. While more evidence is vital, this represents a missed opportunity to DEVELOP that evidence by beginning rollout programs that provide people with a multi along with access to adequate food and clean water. There is also the need to assure people’s capacity to work, creating employment opportunities and the self-generated wherewithal to acquire all these life supports (e.g., through micro-credit programs).
(Frankly, I don’t understand the fuss about GIVING free food and multis to anyone that makes less than $3 a day—it’s inexpensive, saves lives, improves people’s capacity to work, etc. What is this ridiculous philosophy that sneers at people like they’re morally vile if they’re hungry and need food and thus shouldn’t be GIVEN any but meanwhile we collectively stuff MORE money into the hands of the really insanely rich? Most people WANT to work, have pride in their lives and don’t like handouts—but the thresholds for entry into and departure from programs are so low that people die. It’s cruel, insane, cheap—on the part of the major donors, I mean. The people on the ground trying to make it work are heroes trying to make do with damned little.)
Further, recent data have underscored that exclusive breastfeeding reduces the risk of mother-to-child transmission, post-partum, more than bottle-feeding or mixed feeding. At the same time, however, breastfeeding mothers have approximately a 500-calorie increased need to offset the energy expended by breast feeding. Clearly, this means the need for adequate nutrition. Obviously, programs geared toward encouraging women to exclusively breastfeed are doomed to lose the women who don’t have enough to eat!
Another study Rollins reported highlighted that women who are “food insecure” may be less likely to insist upon condom use, may be more susceptible to inter-generational sexual engagements, sex exchange and so forth. Not exactly a shocking finding but provides data for what is obvious. Nutritional security is also a women’s rights issue.
Hunger and starvation could be significantly alleviated if the political will existed both on the part of host nations and the donor communities. Greed, arrogance, corruption and indifference conspire as they ever have in human history to deny these basic, simple necessities of existence. Sustainable development that includes local agriculture, permaculture, community involvement, improved distribution and national storage programs all can work to facilitate access while reducing risks associated with climate change, drought and other challenges to local production. (See, for example, the work of FIAR’s sister organization, the Complementary and Alternative Medicine Initiative (www.ngocami.org) and their efforts in Nigeria to develop permaculture programs, as well as the efforts of The Centre in Harare, Zimbabwe.
Christine Nabiryo from Uganda’s TASO also discussed a number of interesting issues from their experience. Indeed, they noted blips indicating an increased utilization of their services, which include psychosocial evaluation, HIV testing, care and support. These blips coincided with the availability of short-term food support through the UN’s World Food Program (www.wfp.org/english). She noted that many of their clients reported food insecurity as a fundamental challenge in their lives and that many of their clients are women, many of whom lack employment and are widowed. Clearly, however, access to food may further help to increase prevention efforts both through bringing more people in seeking help, testing and access to services but in the other ways described above, where being nutritionally replete may reduce circumstances that result in risky sex, along with all the other benefits of decreasing infection risk, offsetting morbidity and mortality. This isn’t rocket science, kids.
While TASO’s primary mission has been psychosocial support, they realized that they needed to respond to the issues their clientele were raising. As a result, she noted that they start off with food support and social welfare in the short term. But we want to look at opportunities. And we are looking out and have tried to link up with partners that can help us have jump start programs in terms of programs that can help support our clients. Agribusiness, like the Heifer International Project, food security projects like the ACDI/VOCA World Food Program project, into a sustainability process where we can have loans and microfinance to support the clients. So that is our long term vision of a successful sustainable livelihood program.
Dr. Abraham Mosigisi Siika from Kenya’s AMPATH program reported on data from individuals who were eligible for and enrolled in a food program and compared them with a group who were not identified as requiring nutritional interventions. He stated, And there was definitely a difference. The patients who required food were definitely much more immune suppressed. But if you look at this graph is over a period of about one year, the patients that were more immune suppressed, requiring food and got it actually are able to catch up with the other patients. And we think that it does in a way elaborate on success. And this does not for the CD4 cell counts but also for the BMI does catch up with time.
The final session was given by Robin Jackson, an economist who reported data on a study showing that the claim that programs can only provide ARV or prevention OR food, but not both, is untenable. Indeed, without food, there is no life—and happily, their report showed that the cost of providing food support, despite the challenges of distribution, access, sustainability, etc., is quite low and feasible, without necessarily sacrificing funding for prevention or treatment programs. The study looked at 18 countries and 29 programs reviewing costs associated with transportation, staff, warehousing and payment to NGOs. She noted that the daily cost of providing food for a patient and four other family members (5 people) was 70 cents (and this was done last year, taking into account increases in food and fuel prices recently ravaging the world). And for an orphan child to receive 3 meals per day? $0.31.
That cost includes all the supply and other issues—as she put it, from farm gate to family plate. And the food provided 100 kilocarlories of nutrition per day, covering a wide range of food stuffs. She noted that they used data from IMF and FAO to forecast food and fuel costs from 2008 and 2015. Based on these projections, the maximum increase in costs would be 87 cents for nutritional support around care and treatment programs and 37 cents for the orphan and vulnerable children programs. Again as you can see, even with these increases, the total cost is still quite low. They concluded that by 2015, the total global need annually for nutritional support will range from $1.7 to 2.7 billion. That is chump change that also takes into account forecasts of increased food and fuel costs.
Rollins responding to the apparent contradiction noting that not everyone with HIV is poor; that ARV rollout may offset some of the clinical sequelae of HIV infection: So I do not think that they are contradictory. I think in fact they are complementary, these realities. Biologically it is not a disease of poverty, but it clearly has an impact on poverty and food security.
(And if you are one of those fortunate enough to have access to food, please note that if you are further able to assist our efforts, NYBC and FIAR together have been working to contribute in our own small ways to programs that can help save lives!)
One disturbing observation was highlighted in a survey that showed some 37.5% of individuals in the US – and 55.4% globally – changed or stopped taking antiretroviral (ARV) medications due to side effects. Another 27.3% of the 3000 patients polled in 18 countries said they chose not to start therapy for fear of side effects. This makes our mission at NYBC as relevant as ever to try to help reduce the development and/or severity of side effects from medications. And the conference was replete with data on a variety of studies that underscored those side effects.
As with all conferences, a few major stories hit the headlines and a lot of the most interesting stuff is overlooked. Perhaps the most widely reported story was about how the U.S. Centers for Disease Control and Prevention (CDC) had failed to release data they sat on for over a year indicating that the overall numbers of HIV+ individuals in the United States were some 40% higher than previously reported. (Michael Signorile had a good blog on this: http://signorile2003.blogspot.com/2008/08/supressing-numbers-on-hiv.html.) This clearly underscores the dismal failure of the US to address the domestic epidemic, while pandering to anti-scientific religious zealots who press failed “abstinence only” policies and support the government’s refusal to fund and expand syringe access programs (rather than increase funding and access to drug treatment programs). This also fits in horribly well with the extraordinarily racist policies of the government, given that disproportionate numbers of newly infected individuals are African Americans. Not surprising, even at it is devastatingly depressing, from a government that brought us such a “heck of a job” in New Orleans after hurricane Katrina.
Disparate data were reviewed on the effects of abacavir (Ziagen) on veins and arteries—endothelial cell function. Endothelial cells are found in the inner vessel wall lining and are involved with blood pressure, clotting, new vessel formation and inflammation. While higher LDL and triglycerides and low HDL are all risk factors for increased risk of heart trouble, the role of these cells in the expansion and contraction of blood vessels is critical. Damage to them results in the cells producing inflammatory cytokines that cause further damage and increase the risk of heart attacks.
NAM’s HIV and AIDS Treatment In Practice (HATIP) newsletter #115 noted that “Data from the SMART trial provide further evidence that abacavir (Ziagen) may be associated with a higher rate of cardiovascular events, but a pooled analysis of more than 50 clinical trials conducted by abacavir’s manufacturer GlaxoSmithKline did not find any increased risk, attendees heard on Thursday at the XVII International AIDS Conference in Mexico City.” Sadly, pharmaceutical companies have a demonstrated capacity for skewing data to support increasing profits rather than science; I suspect the risk identified in SMART is a more accurate assessment.
Of course, GSK found no difference in toxicity or tolerability in their review of various studies comparing the combination of abacavir/3TC (lamivudine/Epivir) versus tenofovir/emtricitabine. By contrast, an AIDS Clinical Trials Group (ACTG) study found to the contrary, the abacavir arm suffered a higher risk of virological failure or toxicity risks. (For HATIP, see http://www.aidsmap.com/cms1037059.asp).
All ARV have toxicities and tenofovir is no exception. One study showed an increased likelihood of kidney trouble in people with hypertension (high blood pressure) or those on protease inhibitors. All ARV can have toxicities.
Just the same, this does not mean abacavir or tenofovir should be thrown out! HIV meds all have side effects—the bigger and, as ever, unanswered question is: how can the identified risk be reduced? Can agents that help heart health offset this toxicity while permitting continued use of the drug among those who need it? We have some good data on agents like fish oils, niacin, acetylcarnitine, glutamine. More research is needed!
As noted above, there is more than just antiretroviral therapy for managing HIV disease. Clearly, nutrition and adequate hydration are essential basics. Treatments for opportunistic infections are critically important when they arise, along with their accurate diagnosis.
In addition, some more novel approaches to disease management that address host responses may be important to consider. Interleukin-2 (IL-2) is a cytokine, or a kind of messenger made out of protein. This particular cytokine, IL-2, helps to instruct CD4+ T lymphocytes (T cells) in how to proliferate or expand when a pathogen is present. IL-2 has been used in various ways and can dramatically increase T cell counts, particularly among people on effective antiretroviral therapy.
In a recent HATIP article (issue #115), they noted Findings from ANRS 119, the Interstart trial, show that it may be possible to defer HAART treatment for nearly two years by using a limited number of short courses of interleukin-2 to keep CD4 cell counts above the recommended threshold for HAART initiation, Jean-Michel Molina of the University of Paris reported at the XVII International AIDS Conference in Mexico City on Tuesday.
One critical issue about ARV is when to start. Clearly, starting later (e.g., T cells below 200 or 100) makes immune reconstitution more difficult (and may be associated with immune reconstitution syndrome, where the sudden relief from HIV pressure cause all this immune activity against previously quiescent antigens). So starting ARV before T cells hits this threshold is probably wise.
Others suggest that it may be wise to start immediately upon the recognition that one has been infected. However, the data are significantly mixed on whether this is a good strategy or not. While some evidence suggests it may help by allowing the body to develop more robust immune responses to HIV, other data dispute this.
Lactobacillus has potential to prevent HIV transmission via breastmilk
Investigators have developed a technology that has the potential to prevent a mother passing on HIV to her baby during breastfeeding. HIV transmission during breastfeeding can be prevented by a strain of probiotic, Lactobacillus, in the human mouth. Researchers from Lavax and the University of Illinois at Chicago have found a way of preserving this in hot climates without the need for refrigeration. The finding was presented to last week’s 86th General Session of the International Association of Dental Research.
Kaiser Network (http://www.kaisernetwork.org/aids2008/index.cfm)
AIDS Treatment News (www.aidsnews.org/now)
NAM’s AIDSmap (www.aidsmap.com)
SAATHI (South Asian) (www.saathi.org)
European AIDS Treatment Group (http://eatg.org/mailman/listinfo/eatg-forum_eatg.org)