Nutrition and ARV treatment in South Africa - Alastair Duncan, HIV Specialist Dietitian

People living with HIV risk are jeopardising their health if they fail to give equal priority to good nutrition and antiretroviral therapy, says a leading HIV dietitian at Guy’s and St Thomas’ NHS Foundation Trust.

Alastair Duncan has returned from a three-month Winston Churchill Travelling Fellowship in Southern Africa. He says that good nutrition is vital in HIV care, but that messages regarding HIV nutrition are being misunderstood. Antiretrovirals (ARVs) control HIV, but have little direct effect on the immune system. On the other hand, good nutrition is vital in providing the materials needed to help the body rebuild an immune system damaged by the virus.

ARV medication – used by the majority of the 50,000 people living with HIV in the UK – works by preventing the virus from replicating, allowing the immune system to recover. In Southern Africa, however, the roll-out of antiretroviral therapy to people living with HIV is slow, with many millions waiting to receive the life-saving medicines.

Nutrition and Antiretrovirals

During his Fellowship in Botswana, South Africa and Lesotho, Alastair combined teaching and educational activities with observation and learning. He surveyed a range of Health Professionals, and discovered that few understand the role of nutrition in HIV care.

Alastair also observed that many people without access to ARVs were turning to unproven nutritional treatments and traditional herbal medicines.

Alastair said “Some Southern African politicians without any nutrition training have been vociferously advocating beetroot, garlic, lemon and other foods as immune system boosters, even suggesting that antiretrovirals are not necessary if these foods are eaten. When I have talked about this here in the UK, many think of this as a joke, but I think there is nothing funny about tens of thousands succumbing to Aids as a result of following this wilful misinformation. And now the Southern African scientific community is resorting to downplaying the role of nutrition in HIV treatment in order to maintain the momentum in the roll-out of antiretrovirals.”

HIV Nutrition in Southern Africa

In Botswana, a relatively wealthy African country, the majority of people requiring ARVs receive them. However nutrition is only now being integrated into treatment programmes, and this initiative is being hampered by the lack of nutritionists and dietitians – only 24 dietitians are employed country-wide.

South Africa has a well-established network of dietitians supporting the roll-out of ARVs, but the sheer scale of HIV infection is overwhelming, with 5 million people living with the virus. Many HIV clinics operate without nutritional input.

Lesotho is a small mountainous country with poverty, erosion and now drought exacerbating rates of malnutrition where one in three are HIV positive. One third of the country is dependent on food aid, and yet there are only 4 dietitians for the entire country.

Nutrition and Antiretrovirals in the UK

Alastair’s mission not only assists HIV treatment in Southern Africa - it is an important step to better understand patients in the UK.

Some of the most commonly used African herbs – including African potato, Sutherlandia and Leonotis – can prevent ARVs working properly. Alastair said “80 percent of Southern African people visit traditional healers and take herbal medicine and this is mirrored in the UK among African populations.

“Particular herbs negatively interact with ARVs allowing HIV to develop resistance and flourish,” he said.

“Another big concern is that among African communities in the UK the stigma surrounding HIV remains enormous, and some people are too afraid to tell their families they have the disease. This becomes a huge concern because some people choose not to take ARVs because they don’t want to tell their families they have HIV. Or they take ARVs but don’t know how to tell their families they won’t be able to take some herbal medicines.”

Looking to the Future

Alastair says “I want to use my experience to continue research into traditional medicine, nutrition and health practises among African patients here in the UK. A greater understanding of patients of African origin means I can pass on my experience to other health professionals and improve care across the UK.

“I hope to present data at the World Aids Conference in Mexico, August 2008, gathered during my Fellowship. Health Professionals in Southern Africa, the UK and the USA have widely varying levels of knowledge regarding Nutrition and ARVs, and this needs further research and evaluation.”

Reports from Alastair’s Fellowship can be readhere

Facts

• 52,000 people are known to be living with HIV in the UK (about 1 in every 1,000 of the population)

• About 5 million people living with HIV in South Africa (about 1 in 10 of the population)

• Botswana and Lesotho both have 600,000 people living with HIV (about 1 in 3 of each country’s population)

• In the UK and Botswana the majority of those living with HIV are taking ARVs

• In South Africa and Lesotho less than 10% of those requiring ARVs currently receive them

• Malnourished HIV patients attending clinics in Botswana and South Africa are provided with free food parcels and nutritional supplements

• Malnourished people in Lesotho, HIV positive or not, have little access to food supplements other than limited aid provided through the World Food Programme

• In the UK, less than one tenth of one percent of babies born to HIV positive mothers become HIV positive through breast feeding

• In Southern Africa, HIV positive mothers are encouraged to breastfeed as the risk of infant mortality from gastroenteritis is higher than that from HIV