Overview and Nutrition Management of

the HIV/AIDS Patient

CHRI STI NA VALERO
UVA DI ETETI C I NTERNSHI P
Presentation Overview
I. Overview of HIV
I. Definition and Virology
II. Incidence
III. Transmission
IV. Disease Stages
V. Important Labs of the Disease
VI. Opportunistic Infections
VII. Antiretroviral Therapy (ART)
VIII. Life Expectancy
IX. Pregnancy and Breastfeeding
II. HIV/AIDS and Malnutrition
I. Malnutrition Incidence
II. Nutrition Implications of the Disease
III. Medical Nutrition Therapy
I. Goals of Therapy
II. Nutrition Interventions
IV. Role of the RD
V. Case Study
VI. Summary



Learning Objectives
1. Be able to define HIV and AIDS and distinguish between the two.
2. Have a basic understanding of HIV virology.
3. Learn how HIV is transmitted, including the fluids that transmit the disease.
4. Be able to interpret CD4 count and Viral Load.
5. Be able to define opportunistic infection.
6. Have an understanding of the goals of Antiretroviral Therapy and the side
effects of ART drug use.

Learning Objectives, Continued
7. Become familiar with the nutrition implications associated with the disease and its
treatment.
8. Have an understanding of the connection between HIV/AIDS and malnutrition.
9. Learn the importance of MNT and the goals of MNT in this patient population.
10. Become familiar with the common nutrition diagnoses in these patients and identify
appropriate nutrition interventions
11. Be able to define neutropenic diet and identify what this diet entails.
12. Understand the role of the Registered Dietitian in the care of this patient population.


What is HIV?
Human Immunodeficiency Virus- retrovirus that causes progressive failure of the
immune system, allowing life-threatening opportunistic infections and cancers to
thrive. Eventually causes Acquired Immunodeficiency Syndrome
1
HIV infects helper T cells (CD4+ cells), macrophages, and dendritic cells
2

These cells activate the immune response when they detect intruders



What is HIV?
HIV leads to low level of CD4 cells by binding to the surface and becoming a part
of the cells
3
As CD4 cells multiply to fight infection, they make more copies of HIV
3
Leads to gradual decline of CD4 cell count; HIV takes over.
When CD4 cell count declines below a critical level, cell-mediated immunity is
lost and the body becomes progressively more susceptible to opportunistic
infections
3
HIV Virology:
Retrovirus: carries its genetic material in the form of mRNA
4
Targets a host cell
Once inside the cell, the virus uses its own reverse transcriptase enzyme to
produce DNA from its RNA genome
4
Reverse of normal virus: DNA RNA proteins
4
The new DNA is then incorporated into the host cells genome by the integrase
enzyme
4
Now, the host cell treats the viral DNA as part of its own genome
4
Translates and transcribes the viral genes as the cells own genome continues,
and new copies of the virus are made
4

http://www.tbiomed.com/
content/7/1/5/figure/F1?h
ighres=y
HIV Incidence
CDC estimates that >1.1 million people are living with HIV in the US
5
~1 in 6 people (15.8%) are unaware of their infection
5
Over the past decade, the number of people living with HIV has increased
5
HIV Demographics
Gay, bisexual, and other men who have sex with men are most seriously
affected by HIV
5

AIDS affects nearly 7 times more African Americans and 3 times more Hispanics
than whites
5

Estimated new # of HIV infections was highest among individuals aged 25-34 in
2010, followed by age group of 13-24
5


Transmission
Fluids of transmission include:
Blood
Semen/pre-seminal fluid
Vaginal fluid
Breast milk
Sweat, saliva, tears, and urine have not been shown to transmit HIV
5

Transmission
Fluids must come in contact with a mucous membrane, damaged tissue, or be
directly injected into the bloodstream. HIV can enter the body through:
Lining of the anus, rectum, vagina and/or cervix
Opening to the penis
Mouth that has sores or bleeding gums
Cuts or sores
Unbroken skin
5

Transmission
Common ways HIV is transmitted:
Anal, vaginal, or oral sex (most common)
Sharing needles with someone who is HIV+ (2
nd
most common)
Before or during birth
Through breastfeeding
Through transfusion of infected blood or blood clotting factors
oHave no fear, all donated blood in the US is tested for HIV!
5

Progression of HIV
Four Stages of HIV
Acute Infection
Clinical Latency
Symptomatic HIV Infection
AIDS
Two main biomarkers to assess disease progression are CD4+ T-cell Count (CD4
Count) and Viral Load
1


CD4 Count
Used as major indicator of immune function; strongest predictor of disease
progression
1

Used to determine when to initiate ART
1






CD4 Count (cells/mm
3
) Classification
500-1,000 Normal
<500 Symptomatic HIV (Stage III)
<350 Start ART treatment
<200 Qualification for AIDS
1

Viral Load (HIV RNA)
Level of HIV in the blood
Helps monitor disease progression, decide whether to start treatment
If viral load is high, CD4 count is low
No normal viral load
Antiretroviral medications work by keeping HIV from reproducing in the body,
lowering viral load
Strongest indicator of the efficacy of ART
5

Stage 1: Acute Infection
2-4 weeks after infection
50% of people experience symptoms such as fever, malaise, myalgia, swollen
lymph nodes for 2-4 weeks, but they subside after 1-2 weeks
Rarely diagnosed at this stage (symptoms too non-specific)
Large amounts of virus are being produced in the body
oUses CD4 cells to replicate and destroys them in the process
oEventually, viral set point: relatively stable level of virus in the body
High risk of spreading d/t high HIV levels in blood
1

Stage 2: Clinical Latency
(Asymptomatic HIV)
Virus is living and replicating in the body but symptoms are absent
Typically lasts ~10 years for those not on Antiretroviral Therapy (ART)
May live with clinical latency for decades if on ART
Can still transmit disease
5

Stage 3: Symptomatic HIV
When CD4 count reaches <500
More susceptible to developing signs and symptoms
Persistent fevers, chronic diarrhea, unexplained weight loss, loss of LBM
with/without weight loss, thrush, herpes zoster, peripheral neuropathy
HIV has slowly broken down the immune system and it can no longer fight the
virus
5

Stage 4: AIDS: Acquired Immune Deficiency
Syndrome
When CD4 count <200 cells/mm
3

Characterized by increased risk for opportunistic infections (OIs)
Can also be diagnosed with AIDS if one or more OIs develop without a low CD4
count
CDC has named >20 OIs as diagnostic for AIDS
Bacterial infections, viral infections, fungi, parasites
5

Shows CD4 levels and Viral Load over the course of an untreated infection
http://www.newworldencyclopedia.org/entry/AIDS

Life Expectancy with AIDS
Without treatment: 3 years
Without treatment but WITH an opportunistic infection: 1 year
With ART: near normal lifespan! HIV most likely wont progress to AIDS
5

Factors the Shorten Disease
Progression
Older Age
Co-infection with other viruses
Poor nutrition
Severe Stress
Genetic Background
5

Factors that Delay Disease
Progression
Taking ART
Staying in HIV care and listening to doctors
Good nutrition status and LBM before becoming infected with HIV
Genetic background
5

Antiretroviral Therapy (ART)
Sometimes called HAART- Highly Active Antiretroviral Therapy
Introduced in 1996- changed HIV/AIDS outcomes dramatically
Overall AIDS-related deaths, incidence of AIDS, and incidence of opportunistic
infections substantially declined
6
Goal is to achieve and maintain viral suppression, reduce HIV-related morbidity
and mortality, improve quality of life, and restore/preserve immune function
1

>20 antiretroviral agents from 6 mechanistic classes of drugs
1
Antiretroviral Therapy
Pts usually take 3+ ART medications
Treatment is lifelong
Increases risks of side effects, toxicity, metabolic complications
Multiple side effects
Potential Drug-Nutrient Interactions
Non-adherence can lead to drug resistance
1

Drug Classes
Nucleoside and nucleotide reverse transcriptase inhibitors (NRTIs)
Nonnucleoside reverse transcriptase inhibitors (NNRTIs)
Protease Inhibitors (PIs)
Fusion Inhibitors
Chemokine receptor 5 (CCR5) antagonists
Integrase strand transfer inhibitors (INSTIs)
A regimen that includes a combination of drug classes used most often to
combat the disease in multiple ways and to prevent drug resistance
1

Drugs
NRTIs
Emtricitabine (Emtriva)
Lamivudine (Epivir)
Zidovudine (Retrovir)
Abacavir, lamivudine, and zidovudine (Trizivir)
Didanosine (Videx)
Tenofovir (Viread)
Stavudine (Zerit)
NNRTIs
Etravirine (Intelence)
Delaviridine (Rescriptor)
Efavirenz (Sustiva)
Nevirapine (Viramune)
PIs
Amprenavir (Agenerase)
Tipranavir (Aptivus)
Indinavir (Crixivan)
Lopinavir, ritonavir (Kaletra)
Foramprenavir (Lexiva)
Ritonavir Norvir
Darunavir (Prezista)
Atazanavir (reyataz)
Fortovase soft gel (saquinavir
Nelfinavir (Viracept)
CCR5 antagonists
Selzentry (Maraviroc)
Fusion Inhibitors
Enfuvirtide (Fuzeon)
Integrase Inhibitors
Isentress (Raltegravir)
1
Common Side Effects of ART
N/V/D/C
GERD
Fatigue
Gas
Taste changes; especially metallic
Dry mouth
Decreased appetite
Low Zn, Cu, B12 (with NRTIs)
Dyslipidemia
Hypertriglyceridemia
Hyperglycemia
Insulin Resistance
Fat maldistribution (especially with PIs)
Mouth/esophageal ulcers
Anemia
Hepatotoxicity
1

Drug-Nutrient Interactions
Grapefruit juice and PIs
1

Compete with cytochrome P450 enzyme: major enzymes involved in drug
metabolism and bioactivation
1

May cause increase or decrease in blood levels of the drug
1

Timing of food with some medications can effect efficacy and/or cause side
effects
1
Some meds should be taken with a meal while others on an empty stomach
Takes high health literacy and great responsibility for self-care
Costs of ART
As of 2006, ART averaged $10,000 - $15,000/year per patient
7

But, studies show that ART is highly cost-effective
7

Sicker HIV-infected patients have a total annual health care expenditure 2.5
times higher than healthier ones
7


Opportunistic Infections
Infections that do not generally occur in healthy individuals with strong immune
systems


Called opportunistic because they take advantage of the opportunity to
infect a weakened immune system
Can be fatal in people living with HIV/AIDS
ART can help prevent OIs by increasing the number of CD4 cells
1

Opportunistic Infections
Most common OIs include:
Tuberculosis- bacterial infection that affects the lungs
but can spread to other organs
Kaposis sarcoma- can cause lesions on the body and in
the mouth, or even affect internal organs and spread to
rest of body without external signs
Thrush (candidiasis)- fungal infection of the mucus
membrane lining the mouth and tongue
Cryptosporidiosis- parasitic infection of the small
intestine that causes severe chronic diarrhea. Can lead
to severe loss of muscle mass and malnutrition
1


http://en.wikipedia.org/wiki/Kaposi's_sarcoma-
associated_herpesvirus
Possible Comorbidities of HIV/AIDS
Comorbidity Domains Examples
Co-infections Hepatitis, herpes tuberculosis, other OIs
AIDS-defining cancers Kaposis Sarcoma, cervical cancer, non-Hodgkins lymphoma
Non-AIDS defining cancers Lung, anal, or liver cancer, Hodgkins lymphoma
Cardiovascular Disease Heart attack, stroke
Neurological issues Cognitive decline, neuropathic pain
Mental health and addiction issues Substance misuse, depression, anxiety
Blood Disorders Hemophilia, anemia, hemochromatosis, leukemia, thrombosis
Bone disorders Osteopenia, osteoporosis
Metabolic Disorders Lipodystrophy, hyperlipidemia, hyperglycemia T2DM
Kidney Disease n/a
8

https://www.womenshealth.gov/hiv-aids/opportunistic-
infections-and-other-conditions/
Pregnancy, Breastfeeding, and
Transmission
Mother-to-child transmission can occur during pregnancy, labor or delivery, or
through breastfeeding
1

Without ART, there is a 25% chance of mom passing the virus on to baby during
pregnancy or delivery
9

30-45% chance of passing virus to baby through breastfeeding
9
Some ART medications do cross the placenta
11
Baby often receives ART treatment (syrup form) for four weeks after birth
11
Pregnancy Recommendations
CDC recommends:
Starting ART before trying to get pregnant
Taking ART throughout pregnancy and delivery
Delivering baby via C-section
Avoiding breastfeeding if there is a safe alternative
5

Complying with all above recommendations: <2% chance of passing the infection
to baby
5


HIV/AIDS and Malnutrition
HIV/AIDS and Malnutrition
HIV/AIDS
Decreased
Immunity
Increased
Nutrient
Requirements
Malnutrition
Increased
Susceptibility
to Infections
HIV-Related Malnutrition
Suspected mechanisms of weight loss and malnutrition include:
Inadequate dietary intakes
Nutrient losses
Metabolic changes
1

Immune system working harder increased requirements
Insulin resistance
Lipodystrophy
Reduced intestinal absorption d/t damage in villi, inflammation
12

Malnutrition, specifically wasting, is an important predictor of HIV progression
1



Nutrition Implications
Decrease in LBM
Persistent N/V/D
Anorexia
Weight Loss
Malabsorption



Taste Changes
Oral Thrush
Profound Fatigue
Dyspnea
1


Nutrition Implications
HIV-Induced Encephalopathy (AIDS Dementia)- degenerative disease of the
brain caused by HIV infection
Inability to prepare food and feed self
HIV-Induced Enteropathy- effect of HIV on enteric mucosa
Chronic diarrhea, decreased appetite, weight loss, malabsorption, changes in
cognition
Kaposis Sarcoma
Lesions in mouth or esophagus: difficulty chewing and swallowing
Lesions in intestine: obstruction and diarrhea
1


Nutrition Implications
Cytomegalovirus
Enteritis, colitis, weight loss, decreased appetite
Tuberculosis
Malabsorption, weight loss, altered metabolism, fatigue, anorexia
Pneumocystis pneumonia (PCP)
Difficulty chewing and swallowing caused by SOB
Cryptosporidiosis
Cramping, electrolyte imbalances, diarrhea, weight loss
1




Nutrition Implications
Thrush/Candidiasis
Yeast infection- causes mouth and
esophageal sores
Difficulty chewing/swallowing
Taste changes
1


http://www.life-worldwide.org/fungal-
diseases/oral-candidiasis/
Nutrition Implications
HIV-associated lipodystrophy syndrome (HALS)-
abnormal distribution and metabolism of fat
Fat redistribution, insulin resistance,
hypertriglyceridemia
Excess fat accumulation or loss in various parts of
the body- increased fat in trunk, loss of fat in face
and extremities common
With access to ART, new nutrition issues have
arisen due to HALS
HIV-related death has shifted from OIs to chronic
diseases: heart disease and diabetes
1



http://www.maryshinnmd.com/lipodystrophy-in-hiv-patients.html
http://eyewiki.aao.org/HIV-associated_facial_lipoatrophy

AIDS-Related Wasting Syndrome
10% weight loss in 6 months with
Diarrhea >30 days without known cause OR
Fever and chronic weakness >30 days in the absence of a concurrent illness
other than HIV that would explain the findings
1


Medical Nutrition Therapy
Importance of MNT
Malnutrition with HIV infection has been associated with:
Increased mortality
Accelerated disease progression
Loss of muscle protein mass
Impairment of strength and functional status
An unintentional weight loss as little as 5% has been associated with increased
morbidity and mortality
13


Goals of MNT
Optimize nutrition status, immunity, and well-being
Maintain a healthy weight and lean body mass
Prevent nutrient deficiencies
Reduce the risk of co-morbidities
Maximize the effectiveness of medical and ART treatments
1

Nutrition Assessment: Factors to
Consider
Type Factor
Medical Stage of HIV disease
Comorbidities
Presence of Opportunistic Infection
Metabolic Complications
Biochemical measurements
Physical Changes in body shape
Weight or growth concerns
Oral or GI symptoms
Functional Status
Anthropometrics
1

Type Factor
Social Living environment (support from family/friends)
Behavioral concerns or unusual eating habits
Mental health (depression?)
Economical Barriers to nutrition (access to food, financial
resources)
Nutritional Typical intake
Food shopping and preparation
Food allergies and intolerances
Vitamin, mineral, and use of other supplements
Alcohol and drug use
1

Nutrition Assessment
Energy Recommendations
Individuals with well-controlled HIV: mirror same recommendations as healthy
individuals
1

Establish the individuals need to gain, lose, or maintain weight
Vary considerably on case to case basis
Could use 25-45 kcal/kg UBW OR Harris Benedict with stress factor of 1.2-1.8
1

After an OI, nutritional requirements increase by 20%-50%
1

Increased REE common in pts with HIV, especially those with OIs, but TEE
actually decreases
13

Decrease in TEE illustrates that HIV more significantly decreases the infected
persons activity level
13

Thus, decreased energy intake = primary contributor to wasting
13



Protein Recommendations
Much like energy recommendations, vary from case to case basis
Must consider comorbidities, presence of OI
14

Current DRI of 0.8 g/kg BW recommended
14

Deficiency of protein stores and altered protein metabolism occur in HIV/AIDS
patients, but no clinical evidence exists support increasing the proportion of
protein above normal levels
14

With presence of OI, additional 10% is recommended d/t increased protein
turnover
14

Fluid Recommendations
Standard requirements to meet needs: 30-35 ml/kg body weight
14

Consider increasing fluid requirements with fever, N/V/D, exercise
14

Caffeinated beverages do not count
14

Exercise Recommendations
LBM is very important in helping the body resist OIs and to recover after
infection
HIV wasting depletes LBM
1

Resistance exercise important!



Common Nutrition Diagnoses
Inadequate oral food and beverage
intake
Increased nutrient needs
Swallowing difficulty
Altered GI function
Food-medication interaction
Involuntary weight loss


Overweight and obesity
Food and nutrition-related knowledge
deficit
Over-supplementation
Impaired ability to prepare foods or
meals
Inadequate access to food
Intake of unsafe foods
1

Nutrition Interventions: Diarrhea
Bland foods
Avoid fatty, greasy, or spicy foods
Limit caffeine
Low-fiber fruits (like applesauce and bananas)
Avoid dairy products
Replace electrolytes with oral hydration drinks and broths
1

Nutrition Interventions: N/V
Keep log of the causes
Small, frequent meals
Bland foods (rice, potatoes)
Limit high-fat, greasy foods
Avoid foods with strong odors
Cool and clear liquids
Scheduling anti-emetics
1

Nutrition Interventions: Taste
Changes
Use spices and herbs
Avoid canned foods and canned oral supplements
Use plastic utensils
1

Nutrition Interventions: Weight Loss
Nutrient-dense foods
Milkshakes, lean protein, vegetables, fruits, whole grains, trail mixes
Add dry milk or protein powder to oatmeal, casseroles, milkshakes
Add rice, barely, and legumes to soups
Oral supplements
Small frequent meals
1


Nutrition Interventions: Thrush
Soft foods
Oatmeal, scrambled eggs, milkshakes, applesauce
Avoiding spicy or acidic foods
Moisten foods with gravies and sauces
Watch temperature of foods- cold and room temperature foods often more
accepted
Use a straw
1

Nutrition Interventions: Decreased
Appetite
Mild exercise to stimulate appetite
Small, frequent meals
Avoid drinking too much right before or during meals
Avoid carbonated drinks
Eat with company
Choose favorite foods
Appetite Stimulants?
1

Appetite Stimulants
Megestrol acetate
Appetite stimulant that effectively increases weight
15

Weight gain is predominantly exclusively fat
15

May exacerbate DM
15

In a 12-week study of 271 male patients with AIDS wasting, those receiving
800 mg of megestrol acetate/day consumed 500 kcal more/day and gained
4 kg compared with placebo-treated patients (who had weight loss of 0.7
kg), in association with an improved quality of life
16

Appetite Stimulants
Dronabinol
Primary active compound in marijuana- approved by FDA for HIV-associated
anorexia
12

In a RDBPC multicenter trial in patients with HIV-associated weight loss
treated with dronabinol (2.5 mg BID) produced significant increases in self-
reported appetite and decreases in nausea but did not significantly increase
weight over a 6-week treatment period
12,17

Food Safety
Contaminated food = more serious consequences for persons with HIV/AIDS
Avoid raw or undercooked meats, seafood, and eggs
Includes egg yolks and sushi
Ensure only pasteurized milk and cheese products, juices
Prevent cross-contamination: use separate cutting boards for raw meats
Wash fruits and vegetables
Wash hands
1


Neutropenic Diets
Also known as an Immunocompromised Diet
Generally recommended for patients with a WBC count <500 cells/mm3
Eliminates raw fruits and vegetables, meat cooked less than well done, cured
meats, yogurt, aged cheese and prepared salads
14

Role of the RD
RDs Role
Assess patients nutrition status by looking at weight history, medications, lab values,
presence of OIs, etc.
Determine nutrition-related goals for patients, including weight gain/loss/maintenance
goals and exercise goals
Provide appropriate interventions based on nutrition-related goals
Provide recommendations to improve nutritional status, immunity, and quality of life
Address DNIs and manage side effects of ART
Identify barriers to desirable food intake
Encourage adherence to ART
Case Study
55 yo male with hx of HIV on ART admitted for constant watery diarrhea x3 weeks w/ decreased
appetite and severe weight loss.
UBW: 141#; CW: 107#
Last CD4: 67; Viral Load: Undetectable
AST: 36(H); ALT: 244 (H)
Meds: Darunavir, Etravirine, Raltegravir
Reports 8 watery stools/day x7 days
Eating ~1 meal/day + 2-3 Ensures
Tested for 10 different microorganisms
Received Acid-Fast Bacillius smear, bacterial, blood, fungal, stool, and urine cultures

Case Study
Do you need a detectable Viral Load to have HIV?
Based on this patients CD4 count, does he have AIDS?
Why might his AST and ALT lab values be high?
Are there any DNIs this patient needs to be aware of with his specific ART
regimen?
What are some of the nutritional interventions you can recommend for this
patient?
Consider managing diarrhea
Consider hydration status


Summary
People living with HIV experience high rates of side effects and comorbidities
associated with HIV and/or with ART treatments
The specific MNT should be individualized for each patient as there are multiple
comorbidities, medications, and opportunistic infections that affect nutrition
status
To prevent loss of weight and LBM, all HIV-infected patients should be
encouraged to maintain adequate energy intake and engage in moderate
exercise
Questions?
Scuse me I have a question!
References
1. Mahan, L. Kathleen., Escott-Stump, Sylvia., Raymond, Janice L.Krause, Marie V. (Eds.) (2012)
Krause's food & the nutrition care process /St. Louis, Mo. : Elsevier/Saunders.
2. Garg H, Mohl J, Joshi A. HIV-1 induced bystander apoptosis. Viruses. 2012;4: 302043.
3. Cunningham A, Donaghy H, Harman A, Kim M, Turville S. Manipulation of dendritic cell
function by viruses. Current opinion in microbiology . 2010; 13: 524529.
4. http://en.wikipedia.org/wiki/Retrovirus#cite_ref-KurthBannert_1-0.
5. U.S. Department of Health and Human Services. HIV/AIDS Basics. http://www.aids.gov/.
6. Keithley JK, Swanson B, Murphy M et al. HIV/AIDS and Nutrition Implications for Disease
Management. Nursing Case Management. 2000;5:52-62.
7. Center for Disease Control and Prevention. HIV Cost-Effectiveness. 2013.
http://www.cdc.gov/hiv/prevention/ongoing/costeffectiveness/.






References
8. Wilson MG, Chambers L, Bacon J et al. Issues of comorbidity in HIV/AIDS: An overview of
systematic reviews Roundtable Draft. The Ontario HIV Treatment Network. 2012. Accessed at:
http://www.ohtnweb.ca/OHTNWebAP/Publications/PDF/cihr_review_co-
morbidities_report_2010-12-07_final.pdf
9. WHO Department of Nutrition for Health and Development. HIV Transmission through
breastfeeding: a review of the available evidence. 2005. Accessed at:
http://www.who.int/nutrition/topics/Paper_5_Infant_Feeding_bangkok.pdf
10. NAM Aidsmap. Mother-to-baby transmission. 2001. Accessed at:
http://www.aidsmap.com/Mother-to-baby-transmission/page/1044918/
11. NAM. HIV & AIDS Treatment in Practice. NAM. 2005;47. Accessed at
http://www.aidsmap.com/HIV-and-malnutrition/page/1445213/#item1037578.
12. Grinspoon S, Mulligan K, and Department of Health and Human Services Working Group on the
Prevention and Treatment of Wasting and Weight Loss. Weight Loss and Wasting in Patients
Infected with Human Immunodeficiency Virus. Clin Infect Dis. 2003:S69-S78. Accessed at:
http://cid.oxfordjournals.org/content/36/Supplement_2/S69.long




References
14. Macallan DC, Noble C, Baldwin C, Jebb SA, Prentice AM. Energy expenditure and wasting in
human immunodeficiency virus infection. N Engl J Med. 1995;333:83-88.
15. Morrison Healthcare Food Services. Manual of Clinical Nutrition Management. 2000.
Retrieved at: http://library.ncahec.net/reserve/Diet_Manual_10-00.pdf.
16. Wood, AJ, Corcoran C, Grinspoon, S. Treatments for wasting in patients with the acquired
immunodeficiency syndrome. N Engl J Med. 1999;340(22): 1740-1750.
17. Schambelan M, Zackin R, Mulligan K, et al. Effect of testosterone (T) on the response to
megestrol acetate (MA) in patients with HIV-associated wasting: a randomized, double-blind
placebo-controlled trial (ACTG 313) Program and abstracts of the 8th Conference on
Retroviruses and Opportunistic Infections. 2001;236.
17. Beal JE, Olson R, Laubenstein L, et al. Dronabinol as a treatment for anorexia associated with
weight loss in patients with AIDS. J Pain Symptom Manage. 1995;10:89-97.