12 AIDS/HIV in Pregnancy
Chapter 12 / AIDS/HIV in Pregnancy 167
loss and malnutrition in this population, especially in the setting of opportunistic infections [16]. Strategies for symptom management are outlined in Table 12.4.
12.7 FOOD SAFETY
HIV-infected women are more susceptible to bacteria and viruses contaminating food and water [39]. Pregnant, HIV-positive women with negative toxoplasmosis titers should be counseled regarding avoidance of undercooked meats and foods contaminated by soil and animal feces [22]. Food poisoning can lead to weight loss and further compromise immunity to future infections. Proper hand washing, safe food handling and storage, and cooking foods to appropriate temperatures are especially paramount for the safety and health of the HIV-infected pregnant woman. See Table 12.5 for guidelines.
12.8 BREASTFEEDING
De Martino et al. [83] report that the risk of mother to child transmission (MTCT) of HIV through breastfeeding ranges from 4 to 14%, depending upon geographic location and whether feeding was sustained for greater than 1 year. Some risk factors for MTCT through breastfeeding include viral load in the blood [84], viral load in breast milk [85], the mother’s immune status [86], the breast health of the mother [87], and the mother’s nutritional status, including hemoglobin and serum retinol levels. [58, 88–89]. Mothers who are HIV-positive should be educated regarding the risks and benefits of different feed-ing options, includfeed-ing the risk of transmittfeed-ing HIV through breastfeedfeed-ing [1] as well as Table 12.3
Common Antiretroviral Medications Used During Pregnancy and their Nutritional Effects [74, 75]
Possible side effects Administration NRTI
Zidovudine Nausea, vomiting, anemia, neutropenia Can be taken with or without food Lamivudine Nausea, vomiting, peripheral neuropathy Can be taken with or without food NNRTI
Nevirapine Skin rash (most common) Can be taken with or without food PI
Lopinavir/ Diarrhea, headache, nausea, vomiting, Should be taken with food Ritonavir weakness, rash
Nelfi navir Diarrhea, nausea, abdominal pain, Should be taken with food
dizziness, fl atus
Indinavir Kidney stones, abdominal pain, Should be taken on an empty nausea, headache stomach, 1 h before meals or
2 h after meals. Can be taken with light, low-fat meal if stomach upset occurs.
Ritonavir Nausea, vomiting, diarrhea Should be taken with food or liquids Chocolate milk may help to lessen bitter aftertaste
NRTI: nucleoside reverse transcriptase inhibitor; NNRTI: non-nucleoside reverse transcriptase inhibitor;
PI: protease inhibitor
an increased mortality rate among HIV-infected pregnant women who breastfeed [90].
The metabolic demands of lactation as well as the metabolic demands of HIV infection are thought to lead to nutritional impairment and subsequently, an increased risk of infant mortality [90].
It is recommended that mothers who can provide an alternate feeding method that is acceptable, affordable, sustainable, and safe are advised to do so [91]. The Centers for Disease Control and Prevention (CDC) recommend that HIV-infected pregnant women in the United States avoid breastfeeding [92].
For those mothers who choose to breastfeed, the quality of the breast milk is linked to the nutritional status of the mother, specifically the concentrations of both macronutrients and micronutrients as well as immunologic properties [17]. Mixed feeding, which is
Table 12.4
Nutrition and Dietary Management of Common HIV Symptoms Anorexia
• Eat small, frequent meals.
• Capitalize on moments when you are hungry. Keep snacks readily available.
• Choose nutrient dense foods (peanut butter, cheese, yogurt).
• Avoid foods of low nutrient value (diet foods and beverages).
Nausea and vomiting
• Keep something in your stomach to curb nausea (i.e. crackers).
• Choose bland foods that are easy to digest such as toast, pasta, oatmeal, turkey, and pudding.
• Avoid greasy, high fat foods.
• Avoid spicy or highly seasoned foods.
Diarrhea
• Select binding foods such as bananas, toast, rice, and applesauce.
• Avoid high fat foods and lactose-containing foods.
• Drink adequate fl uids to replace losses (water, sports drink, juices).
Sore mouth and throat
• Select smooth textured foods, such as pudding, yogurt, scrambled eggs, bananas, and applesauce.
• Avoid foods that are acidic, spicy, and that have rough edges and textures.
• Add moisture to foods with broths and gravies.
• Use a straw to drink liquids.
Table 12.5
Guidelines for Food Safety
• Ensure proper hand washing.
• Handle and store food in a safe manner (i.e. separate raw foods from prepared foods).
• Cook foods to appropriate temperatures.
• Store and keep foods at appropriate temperatures.
• Avoid raw or undercooked potentially hazardous foods (i.e. meat, poultry, fi sh, eggs).
• Use water from a clean and safe water supply.
Chapter 12 / AIDS/HIV in Pregnancy 169 defined as breastfeeding coupled with other foods and liquids by mouth, appears to add to transmission risk in the first 6 months of life [93]. Longer durations of breastfeeding by HIV-infected mothers are associated with an increased risk of HIV transmission to their infants and early weaning from human milk (i.e., at 6 months of age) is recom-mended to limit the child’s exposure to HIV-infected human milk [90].
12.9 GOALS OF NUTRITION CARE
The following goals for maternal nutritional care have been outlined by Lwanga [94]:
1. Improve nutritional status, maintain weight, prevent weight loss, and preserve lean body mass.
2. Ensure adequate weight gain during pregnancy.
3. Ensure adequate nutrient intake by improving dietary habits and encouraging appropriate macronutrient and micronutrient intake.
4. Prevent foodborne illness by promoting food and water safety.
5. Manage symptoms that affect nutrient intake to minimize the impact of secondary infec-tions on nutritional status.
The general goal of nutritional assessment and interventions is to improve nutritional status, enhance quality of life, and prolong the survival of the mother [95].
12.10 APPROACHES TO NUTRITIONAL CARE
The following is a recommended approach to nutritional care for the HIV-infected pregnant woman and includes a baseline nutritional assessment, nutritional counseling, and follow-up nutritional care.
12.10.1 Nutritional Assessment
A baseline assessment should be made at the first prenatal visit and follow-up care should be provided at subsequent visits. The initial nutritional assessment should include base-line anthropometric measurement such as weight, height, BMI (height [cm]/kg [m2]), and mid–upper arm circumference (MUAC) [23]. The BMI will indicate whether the woman is at an appropriate weight or is underweight or overweight at onset of pregnancy. This infor-mation will enable the provider to make specific weight gain recommendations and allow for tracking of weight gain during pregnancy. Additionally, women who have a MUAC of <23 cm are at even greater nutritional risk [96, 97]; thus, this anthropometric marker may indicate the need for more aggressive nutritional intervention. Biochemical assessment measures including serum albumin, transferrin, hematocrit, creatinine, urea nitrogen, lipids, and micronutrients indicate disease prognosis and potential complications [98, 99]. These markers should be included in the initial assessment and followed throughout pregnancy.
The initial assessment takes into account the diet history of the woman as well as any symptoms or problems that might hinder adequate intake. Typical dietary, appetite, gastrointestinal symptoms (i.e., nausea, vomiting, diarrhea, and constipation), difficulty with chewing and swallowing, food allergies, ethnic and cultural food practices, and household food security should be considered and included in the assessment. Further-more, all medications and supplements as well as complementary therapies should be investigated in order to determine possible drug-nutrient interactions.
12.10.2 Nutritional Counseling
Weight gain goals should be set based on the woman’s BMI at baseline. If underweight (BMI < 19.8 kg/m2), then she needs to gain 28–40 lb during pregnancy. If at appropriate weight (BMI 19.8 – 26 kg/m2), then she needs to gain 25–35 lb during pregnancy. If over-weight (BMI > 26–29 kg/m2), then she needs to gain 15–25 lb during pregnancy. If obese (BMI > 29 kg/m2), then she needs to gain at least 15 lb during pregnancy (refer to Table 12.1).
Energy needs are dependent on whether the woman is asymptomatic or symptomatic at the time of assessment. If asymptomatic, then her calorie needs are increased by 10%
plus an additional 300 kcal per day on average during pregnancy (500 kcal per day during lactation). (see Chaps. 1 and 18, “Nutrient Recommendations and Dietary Guidelines for Pregnanat Women” and “Nutrition Issues During Lactation”). If symptomatic, then her calorie needs are increased by 20–30% plus an additional 300 kcal per day during preg-nancy (500 kcal per day during lactation).
Protein needs are estimated to be approximately 1 g/kg/day.
Encourage a diet that is nutritionally adequate and varied. Additional multivitamin and min-eral supplementation is also encouraged. Specific nutrients of importance are iron and folate.
The DRI for iron is 27 mg/day and for folate is 600 mcg per day. While prenatal vitamins vary, most provide approximately 800–1,000 mcg of folic acid and 30 mg of iron per dose.
Provide counseling regarding breastfeeding and risk of MTCT of HIV.
Address food safety with regard to proper hand washing, safe food handling and storage, and safe cooking temperatures.
Provide counseling for women on ARV treatment regarding meal planning, symptom management, and the metabolic changes associated with ARV therapy.
12.11 CONCLUSION
Nutrition assessment and counseling are critical components of the care plan for HIV-infected pregnant women. The compounding effects of pregnancy and HIV-infec-tion place HIV-infected pregnant women at greater nutriHIV-infec-tional risk. Adequate weight gain and nutrient intake and symptom management are especially challenging for this population. Intervention in terms of care for HIV-infected pregnant women tends to be directed towards pregnancy outcomes and fetal health, more so than to maternal health and maternal morbidity and mortality. Given the growing population of HIV-infected women of childbearing age, there is a need for more research to determine the best nutrition and medical care plans for promoting both maternal and fetal health.
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