Nutritional management of HIV in the era of
highly active antiretroviral therapy: a review of
treatment strategies
Dannae Brown and Marijka Batterham
Abstract The introduction of highly active antiretroviral ther-
apy (HAART) has resulted in marked improvements in HIV
disease outcome with improved long-term survival. These
changes in disease treatment have necessitated changes in nutri-
tional management strategies. Weight loss continues to occur in
the HAART era and dietary counselling, oral supplementation,
enteral and parenteral nutrition and pharmacological agents are
treatment options. The introduction of HAART has been compli-
cated by drug and nutrient interactions, the load of pills to be
taken and side effects that all need to be considered in a dietary
assessment. HAART has been associated with peripheral lipo-
dystrophy or fat redistribution syndrome—a syndrome
characterised by various combinations of hyperlipidaemia, insu-
lin resistance, loss of peripheral fat stores, visceral adiposity
and/or dorso-cervical fat accumulation. This syndrome has com-
plicated the nutritional management of HIV and potential
treatments and may require dietary modification, exercise and
pharmacological treatments. Each patient could have a combina-
tion of different abnormalities all requiring an individually
modified treatment strategy. Nutritional management of people
with HIV/AIDS has become extremely complex and knowledge
of conventional and current issues is essential to assist people
maximise nutritional status. (Aust J Nutr Diet
2001;58:224–235)
Key words: HIV, AIDS, nutritional management, weight loss,
highly active antiretroviral therapy
Introduction
The aim of this paper is to address the current nutritional
management guidelines for people with HIV/AIDS. The
treatments discussed here are complimentary to the nutri-
tional issues discussed in the previous paper (1).
Weight loss
Treatments for HIV-associated weight loss
Weight loss still occurs in people with HIV/AIDS even in
patients receiving highly active antiretroviral therapy
(HAART) although the prevalence is not clear. Many peo-
ple with HIV/AIDS already had advanced disease before
HAART was introduced, and even in those who respond
to treatment, viral resistance may develop thus reducing
the effectiveness of the drugs. Due to the side effects of
HAART and lifestyle changes necessary to take this treat-
ment effectively, some people choose not to take therapy
or, despite a good virological response, do not tolerate
therapy. For these people with HIV/AIDS, nutritional
management remains focused on maintaining nutritional
status and treating the symptoms of disease. Management
strategies for weight loss have progressed since they were
last published in this Journal (2) and so they are discussed
in detail below.
224 Australian Journal of Nutrition and Dietetics (2001) 58:4
Dietary counselling
Intensive nutritional intervention is recommended early in
the course of HIV infection to maintain nutritional
status (3,4). When weight loss has occurred, nutritional
intervention with or without oral supplementation (3,5–7),
enteral-nasogastric nutrition (8), percutaneous endoscopic
gastrostomy nutrition (9,10) and parenteral nutrition (11–14)
has been trialled with varying degrees of success in
increasing weight and improving body composition.
Few studies have examined the effect of nutritional
counselling alone to improve dietary intake and weight in
people with HIV/AIDS. Dowling et al. (5) conducted a
prospective study to investigate the effect of dietary coun-
selling on dietary intake, weight and body composition in
34 people with HIV/AIDS over 12 weeks. While nutrient
intake increased, body composition was not significantly
altered. Chlebowski et al. (6) examined the effect of die-
tary counselling in 108 people with HIV/AIDS over a six-
month period in a prospective cohort study. Weight
declined despite adequate energy intake. Van Niekerk and
colleagues (15) investigated the effectiveness of nutritional
counselling for treating weight loss in people with
HIV/AIDS not receiving antiretroviral therapy. A mean
weight increase of 3.5 kg was seen in 32 of the 60 subjects
versus a mean weight increase of 2.0 kg in only six of the
28 matched controls.
Other research has investigated the role of oral nutri-
tional supplementation in addition to nutritional
counselling. Rabeneck et al. (7) compared dietary counsel-
ling with oral nutritional supplementation (treatment
group) to dietary counselling without nutritional supple-
mentation (control group) over a six-week period in 118
people with HIV/AIDS who had lost weight. They found
no significant differences in the change from baseline in
weight or body composition between the two groups;
mean weight decreased by 0.1 kg in both groups; fat free
mass increased in the treatment group by 0.9 kg and
decreased in the control group by 0.4 kg (P = 0.077).
Around 50% of patients in each group were able to
The ‘Nutrition for Life’ program is funded by Merck, Sharpe and Dohme
Australia
HIV Medicine Unit, St Vincent’s Hospital, Darlinghurst, New South
Wales
D. Brown, MND, HIV Dietitian
Smart Foods Centre, University of Wollongong, New South Wales
M. Batterham, Msc (Nutr Diet), PhD, APD, HIV Nutrition Consultant
‘Nutrition for Life’ progam (formerly HIV Dietitian, Department of
Nutrition and Dietetics, Royal Prince Alfred Hospital, and HIV Dietitian,
Nutrition Unit, The Albion Street Centre, Sydney, NSW)
Correspondence: M. Batterham, Smart Foods Centre, University of
Wollongong, Northfield’s Ave, Wollongong, NSW 2522. Email:
marijka@uow.edu.au

achieve their recommended dietary intake for weight gain.
Stack et al. (3) investigated the effects of dietary counsel-
ling including the provision of a high energy, high protein
supplement for approximately six weeks in 17 people with
HIV/AIDS. Twelve of 17 people were able to maintain or
gain weight (mean gain 1.1 kg). However, the remaining
five continued to lose weight.
Schwenk et al. (16) examined the effects of dietary
counselling to increase intake with and without the addi-
tion of oral supplements. They found a significant
increase in fat free mass over eight weeks in both groups.
However, the weight change was not significant. Berneis
et al. (17) also investigated the effects of nutritional sup-
plements with dietary counselling (n = 8) or dietary
counselling alone (n = 7) on body composition and whole
body protein catabolism in people with HIV/AIDS. In
contrast they found only the group receiving the oral sup-
plement with dietary counselling had significant increases
in fat free mass (2%) and a significant reduction in protein
catabolism.
In most cases dietary counselling for weight gain was
described as education regarding a high energy, high pro-
tein diet with individual modifications to minimise
symptoms (e.g. foods low in fat and insoluble fibre in
order to minimise diarrhoea) (3,5,7,18). In some of these
studies the education was poorly described and referred to
as following standard nutritional principles (6,19).
In one study parenteral nutrition has been shown to
significantly increase weight (+8 kg), fat free mass (9%)
and body cell mass (15%) in malnourished people with
HIV/AIDS when compared with dietary counselling in
which weight decreased by 3 kg, fat free mass decreased
by 5% and body cell mass decreased by 12% (13). In con-
trast Kotler et al. (11,20) found no significant increase in
body cell mass in people with HIV/AIDS receiving total
parenteral nutrition. The weight gain in both these studies
was primarily attributable to an increase in fat mass.
Percutaneous endoscopic gastrostomy feeding has
been shown to increase weight (3.3 kg), although the
mean increase in body cell mass was not significant (10).
However, some subjects had opportunistic infections and
experienced decreases in body cell mass while the others
had a significant mean increase of 1.2 kg (10). Another
study demonstrated significant increases in both body cell
mass and fat mass in clinically stable people with
HIV/AIDS fed through a percutaneous endoscopic gas-
trostomy tube (9).
Specialised supplements have also been trialled for
their effectiveness in promoting weight gain and immune
improvement in people with HIV/AIDS. A small pilot
study in three HIV-positive subjects showed weight gains
of 2 kg to 7 kg over three months when taking whey pro-
tein supplements (21). Whey protein supplementation for
14 weeks resulted in significant increases in weight (both
fat free and fat mass) in HIV-positive women (22). A com-
bination of β-hydroxy β-methylbutyrate, glutamine and
arginine has also been shown to increase weight and fat
free mass when compared with placebo in a double-blind
study of HIV-positive people with weight loss over an
eight-week intervention period (23). Another randomised
double-blind placebo-controlled study showed that a com-
bination of glutamine and anti-oxidant supplement
resulted in a significant increase in the body cell mass in
HAART treatment strategies
the treatment group compared with the placebo group
after a 12-week period (24). In contrast, a study comparing
two oral liquid supplements with and without arginine and
n-3 fatty acids for six months showed similar body weight
increases in both groups (25). A study investigating the
effects of n-3 fatty acids over a ten-week period after a
ten-week control period showed no significant change in
body weight or composition with supplementation (26).
Some of these results are promising but further
research regarding the doses and optimum regimens is
required before these supplements could be routinely rec-
ommended for treating weight loss in people with
HIV/AIDS.
Pharmacological agents in the management of HIV-
associated appetite and weight loss
Several pharmacological agents, usually marketed for
some other conventional use, have been investigated for
their capacity to stimulate appetite and/or promote thera-
peutic weight gain in people with HIV/AIDS.
Hormonal agents with anabolic action
Testosterone
Hypotestosteronaemia was a frequent finding in HIV-
positive men prior to the HAART era. Pre-HAART esti-
mates suggested approximately 50% of HIV-positive
males were likely to experience hypogonadism related to
undernutrition, chronic illness or medications (27). Data
relating to the degree of hypogonadism since the HAART
era are limited but Berger et al. (28) suggest the prevalence
of hypogonadism may be diminishing with more effective
therapy (17.3% of 127 studied).
Grinspoon et al. (29) demonstrated an increase in fat
free mass of 2.0 kg in hypogonadal men with wasting
receiving 300 mg of testosterone every three weeks for six
months versus a decrease of 0.6 kg of fat free mass in the
placebo group (P < 0.05). There was no significant
change in weight or exercise capacity. Treatment at this
dose for 12 months resulted in a mean increase in fat free
mass of 3.7 kg. More recently this same group of
researchers demonstrated that weekly treatment with
200 mg testosterone for 12 weeks resulted in an increase
in muscle mass assessed using computed tomography (30).
Dehydroepiandrosterone
Dehydroepiandrosterone (DHEA) is produced by the
adrenal glands and converted to androgens and/or oestro-
gens in target tissues. Concentrations have been shown to
decrease in people with HIV/AIDS and to be related to the
amount of weight lost (31). A pilot study of the effective-
ness of dehydroepiandrosterone in 32 people with
HIV/AIDS showed significant improvements in mood and
body cell mass over an eight-week treatment period (32).
While this treatment warrants further investigation, it is
not currently available in Australia for routine use.
Nandrolone decanoate
Prior to the introduction of recombinant human erythro-
poietin, nandrolone decanoate (a testosterone analogue)
was used for the treatment of anaemia associated with
chronic renal failure. Nandrolone decanoate use in men
Australian Journal of Nutrition and Dietetics (2001) 58:4 225
HAART treatment strategies
with HIV/AIDS has been reported to result in significant
increases in both weight (range 1.6 to 4.9 kg) and lean
body mass (range 1.9 to 3.9 kg) (33–36).
Recombinant human growth hormone
Schambelan et al. (37) conducted a randomised placebo-
controlled study of growth hormone at a dose of 0.1 mg
per kilogram per day in 178 people with HIV/AIDS with
weight loss. Weight (mean ± sd, 1.6 ± 3.7 kg) and fat free
mass (3.0 ± 3.0 kg) increased significantly and fat mass
decreased significantly (1.7 ± 1.7 kg) in the treatment
group. On the basis of these results recombinant human
growth hormone is available for use in the USA for HIV-
associated wasting on a compassionate basis, and is cur-
rently available as part of a clinical trial for HIV-
associated wasting in Australia.
Hormonal agents without anabolic action
Megestrol acetate
Megestrol acetate, a synthetic progesterone analogue, was
initially used in the early 1980s as a treatment for
advanced breast cancer. Weight gain and appetite stimula-
tion were noted as unwanted side effects in many patients
at conventional doses.
Three large randomised placebo-controlled
studies (38,39) have investigated the effectiveness of meg-
estrol acetate, at various doses, for treating HIV-
associated weight loss. Significant weight increases of
about 2 kg to 3 kg were found at doses of 800 mg per day.
The body composition assessments conducted in two of
the three studies showed an increase in weight, primarily
in fat mass (38,39). One group also reported a significant
mean increase in fat free mass of 1.14 kg in the treatment
group compared with a decrease in the placebo group (38).
However, the change in fat free mass was not significant
in the other study (39).
Glucocorticosteroids
Glucocorticosteriods are used for the treatment of steroid
responsive conditions such as inflammation, and also as
appetite stimulants in oncology patients (40).
Prednisone (metabolically inactive) is converted to
prednisilone (metabolically active) in the liver. Anecdo-
tally, Coodley (41) reports doses of 40 mg to 80 mg per
day of prednisone have been useful in improving weight
in an HIV-positive patient population. Dexamethasone is a
high potency corticosteroid that has also been used to
increase appetite but not weight in cancer patients (42). A
small study of dexamethasone in five people with
HIV/AIDS with disseminated mycobacterium avium com-
plex infection and progressive weight loss, as an adjunct
to their antimicrobial therapy (43) demonstrated substan-
tial weight gain (12% to 50% body weight prior to steroid
treatment, P < 0.03) in all subjects.
It is likely that the increase in weight experienced with
glucocorticosteroids is primarily fluid retention resulting
from the mineralocorticoid actions (44), although body
composition has not been assessed.
226 Australian Journal of Nutrition and Dietetics (2001) 58:4
Non-hormonal agents
Dronabinol
Dronabinol (delta-9-tetrahydrocannabinol) contains the
neuroactive part of the marijuana plant and was trialled
initially as a therapy for nausea and vomiting associated
with cancer chemotherapy, following anecdotal reports of
efficacy (45). This treatment is approved for use in HIV-
associated wasting in many countries including Australia,
but it has been taken off the market by the distributor.
Although dronabinol has been found to be an effective
antiemetic agent, randomised controlled studies were una-
ble to demonstrate a significant effect on weight in wasted
people with HIV/AIDS (45,46). Dronabinol use was associ-
ated with a high incidence of neuropsychological side
effects including dizziness, euphoria and confusion and
limit the acceptability of this agent (45,46).
Smoked marijuana is also currently under clinical
investigation in the United States as an appetite enhancing
agent for people with HIV.
Cyproheptadine
Cyproheptadine is an antihistamine with antiserotonergic
properties. The conventional use is for the treatment of
acute and chronic allergies, pruritus and vascular head-
aches. It has previously been used as an antidepressant
and to promote weight gain for patients with anorexia
nervosa (47–49).
Summerbell et al. (50) observed weight gain (mean
3.1 kg) in only three of seven people with HIV/AIDS-
associated weight loss treated with cyproheptadine but the
increases in appetite and intake were significant. The
authors concluded that cyproheptadine should be the first
line of treatment for HIV-related weight loss as it pro-
duced an increase in appetite and moderate weight gain in
some patients without the side effects of megestrol
acetate.
Treating weight loss
Dietary counselling should be trialled as the first line of
management for people with HIV-associated weight loss.
As there is some discrepancy in the literature about the
effectiveness of dietary counselling alone or in combina-
tion with oral supplements, it is important that
practitioners consider studying and documenting the
effectiveness of their interventions.
Nandrolone decanoate and testosterone are often pre-
scribed for treating HIV-associated weight loss. Although
formal protocols do not exist, other treatable causes of
weight loss should be excluded and dietary counselling
trialled before the use of these agents is contemplated.
Presently the literature indicates that testosterone should
be prescribed where there is evidence of hypogonadism,
and nandrolone decanoate should be used in eugonadal
men with wasting (51). Although nandrolone decanoate
has previously been used in women, there is no literature
regarding the effectiveness of this agent in women with
HIV. Testosterone supplementation has been studied with
success at low doses in women with HIV/AIDS (52).
Megestrol acetate is an effective appetite and weight-
promoting agent in people with HIV/AIDS. It is, however,
 HAART treatment strategies

associated with side effects related to its glucocorticoid
activity, particularly with long-term use (38).
Recently, we conducted a controlled open label study
to compare the effectiveness of nandrolone decanoate,
megestrol acetate and dietary counselling in people with
HIV/AIDS-associated weight loss (36). Weight gain was
significant in all three groups (dietary counselling mean
+1.1 kg, nandrolone decanoate +4.0 kg, megestrol acetate
+10.2 kg). However, increases in fat free mass were sig-
nificant only in the nandrolone decanoate (3.5 kg) and
megestrol acetate arms (mean 2.8 kg) over the 12-week
treatment period. The increase in percentage body fat
mass was significant only in the megestrol acetate arm
(+7.8%). We concluded that when dietary counselling
fails, megestrol acetate should be the treatment of choice
in palliative cases where weight and appetite increase
were desirable. However, nandrolone decanoate was the
preferred treatment for those with asymptomatic disease
where an increase in fat free mass was the primary aim.
Due consideration must be given before the decision
to recommend one of these agents is made. The weight
gain achieved using the pharmacological therapies is usu-
ally only a few kilograms, and the long-term
consequences of using these agents have not been evalu-
ated. The treatments also differ significantly in their cost
to the patient. Currently used agents, usual dose and costs
are shown in Table 1.
At present there is no literature demonstrating
improved survival with increasing weight or changes in
body composition. However, it is assumed that increased
survival will be the benefit of reversing losses in weight
and fat free mass. Therefore the choice of intervention
rests on the benefits to quality of life, enhanced perform-
ance, physical function and the potential to increase
survival time. In palliative patients or those with advanced
disease the focus of dietary counselling and treatment
should be on quality of life and therefore weight gain and
appetite should be maximised regardless of the composi-
tion of the change. In those with moderate disease and a
long life expectancy, increases in fat free mass are desira-
ble to maximise the potential survival benefit, while at the
same time improving quality of life and enhancing per-
formance and physical function (53,54). As the natural
course of HIV disease progression seems to result in a
decrease in fat free mass, even small gains or maintenance
may provide survival benefit over a period of years.
Exercise
One study investigating the association between HIV dis-
ease progression and exercise in a cohort of 156 people
with HIV/AIDS found that moderate physical activity
(three to four times a week) may slow HIV disease
progression (55). Resistance exercise has been shown to
improve muscle mass in men with HIV/AIDS (30,56). Aer-
obic exercise has been shown to decrease fatigue and
improve aerobic capacity (57–59). However, a recent
Cochrane review concluded that most studies investigat-
ing aerobic exercise interventions in people with HIV
were underpowered because of small sample sizes and
high drop out rates and that it was difficult to make firm
recommendations about an adequate regimen for
effect (60). Nevertheless, current research suggests exer-
cise should be recommended for people with HIV/AIDS
and an appropriate regimen discussed with an experienced
HIV physiotherapist or exercise scientist.
HAART-related nutritional issues
Drug and food interactions
Most antiretroviral therapies require dietary modification
to maximise absorption (see Table 2). Indinavir, a protease
inhibitor, is perhaps the most restrictive. This medication
is taken three times daily, eight hours apart. For one hour

Table 1. Dose, approximate cost and availability of pharmacological agents for treating HIV-associated weight loss in
Australia (adapted from 97)
Daily cost to patient
Name Usual dosage (approximate $AUD) Availability
Testosterone 200–250 mg intramuscular $1.60–$2.00 Yes
per 2–3 weeks
Dehydroepiandrosterone (DHEA) 200–500 mg per day as 2–5 $2.00–$6.00 No (only available through special
capsules access scheme by application to the
Therapeutic Goods Administration)
Nandrolone decanoate 100 mg intramuscular per 2 $2.80 ($76 for 4 × 50 mg) Yes
weeks
Recombinant human growth 1.4–6 mg subcutaneous per $260 ($1000 US per No (placebo-controlled studies at some
hormone day week) Australian centres)
Megestrol acetate 400–800 mg per day as 4–5 $5.00–$10.00 Yes
tablets
Prednisolone (not available) $7 on PBS(a) Yes
Dexamethasone 0.5–4 mg per day as 2–4 mg $0.15 on PBS(a) Yes
tablets
Dronabinol 2.5–5 mg per day as 1–2 $4.00–$8.50 Yes, with special approval. Although no
tablets longer sold in Australia, some patients
import this treatment.
Cyproheptadine 12–32 mg per day as 3–8 $0.30–$0.70 Yes
tablets
(a) PBS, Pharmaceutical Benefits Scheme which provides a discount for patients receiving social security benefits.

Australian Journal of Nutrition and Dietetics (2001) 58:4 227

HAART treatment strategies
before and two hours after each dose (i.e. nine hours of the
day) only snacks less than 1200 kJ, with less than 2 g of
fat and 5 g of protein are allowed. Missed doses are asso-
ciated with reduced drug efficacy (61). Often more than
one HAART medication requires dietary adjustments.
These changes may be overwhelming for the patient, par-
ticularly if they are taking antiretroviral medications for
the first time. Dietitians working with this group should
be aware of the dietary specifications and design an
appropriate meal plan that both maximises nutritional
intake and drug absorption. Liaising with the pharmacist
to ensure the patient receives consistent and accurate
information is important, for example, sometimes ritona-
vir can be prescribed with indinavir to eliminate the
dietary restrictions.
Antiviral pill load
Some commonly prescribed HAART regimens contain up
to 34 tablets per day (excluding prophylactic or other ther-
apeutic agents) and some of the tablets and capsules are
large and difficult to swallow. Most antiretroviral medica-
tions are taken two or three times a day, and it can take up
to 15 minutes each session to take the pills. The efficacy
of the regimen is reduced if medications are not taken to a
strict schedule. All of this must be considered in a dietary
education session. Achieving an adequate dietary intake
with these restrictions is often challenging. Careful meal
planning around the times of the day when appetite is
great and consideration of the food specifications for par-
ticular medications is essential.
Side effects
Most antiretroviral treatments are associated with side
effects. In our patient population in Sydney, Australia,
66% (n = 99) of those surveyed reported diarrhoea, 48%
(n = 72) nausea and 45% (n = 67) loss of appetite (62).
Most of these patients (84%) were receiving HAART and
most attributed their symptoms to their therapy (62). Rei-
jers et al. (63), reported side effects in patients receiving
quadruple antiretroviral therapy and found diarrhoea
present in 49 (lasting for an average of 98 days) and nau-
sea in 13 out of 65 patients. Seven patients had to change
therapy for reasons of toxicity within the first 26 weeks of
treatment.
Diet sheets providing information on symptom man-
agement (e.g. nausea, diarrhoea and loss of appetite) are
available from the Dietitians Association of Australia
NSW HIV/Oncology Interest Group. However, there are
some points worth mentioning here about nausea and diar-
rhoea specific to HIV in the HAART era. (The Dietitians
Association of Australia NSW HIV/Oncology Interest
Group can be contacted through the national office of the
association at 1/8 Phipps Close, Deakin ACT 2600.)
Nausea and loss of appetite
Nausea is listed as a potential side effect of most antiretro-
viral agents and is often the cause of a reduced appetite in
those taking HAART. Maintaining nutritional intake can
be difficult, particularly in patients with chronic daily nau-
sea. In some cases adhering to food specifications can be
helpful, for example the manufacturers recommend riton-
avir, a protease inhibitor, be taken with food, to avoid
nausea. When standard nutritional interventions fail, phar-
228 Australian Journal of Nutrition and Dietetics (2001) 58:4
macological antiemetics and/or an appetite stimulant (e.g.
megestrol acetate, cyproheptadine) should be considered.
Diarrhoea
Diarrhoea is also commonly listed as a side effect of
antiretroviral medications. It appears to be more prevalent
in those people with HIV/AIDS receiving protease inhibi-
tors (particularly ritonavir or nelfinavir) as part of their
antiretroviral regimen. In some severe cases, this can be
extremely debilitating. Standard anti-diarrhoeal medica-
tions can be helpful. However, issues concerning
increased pill load and rebound constipation are com-
monly reported.
Dietary intervention can help, in some cases, to allevi-
ate symptoms. Soluble fibre supplementation, in the form
of psyllium husks, is usually the first line of dietary treat-
ment and has been shown to be successful (64,65). There is
anecdotal evidence that treatment with one or two heaped
teaspoons of psyllium husks twice a day, with around
300 mL of water has been successful. Fat intolerance is
often reported with nelfinavir-induced diarrhoea, and
symptoms can be significantly reduced with a reduction of
dietary fat, but care needs to taken to avoid weight loss.
With chronic diarrhoea, lactose intolerance should also be
considered.
Other treatments reported in the literature for control-
ling diarrhoea induced by protease inhibitors include
calcium supplementation (66), pancreatic enzymes (67),
and oat bran (68). The cost, availability and burden of pills
all need to be considered when selecting a particular
intervention.
Peripheral lipodystrophy syndrome or fat
redistribution syndrome
As discussed in the previous article lipodystrophy is com-
mon in people with HIV/AIDS in the HAART era. The
long-term implications of lipodystrophy are not estab-
lished, although it is likely that hyperlipidaemia and
hyperglycaemia will have negative consequences if
uncontrolled. Of equal importance, particularly in the
short term, is the impact these body shape changes have
on quality of life, self-esteem, body image and drug
compliance.
At present there are no effective treatments for lipo-
dystrophy. As the underlying mechanism is unclear, most
treatment strategies are based on symptom control. More
research is needed in this area to ascertain the safety and
efficacy of specific interventions. Potential intervention
strategies are discussed below.
Diet and exercise
As with the general management of hyperlipidaemia, diet
and exercise have been suggested as the first line of
treatment (69). A working group of the adult AIDS clinical
trials group (AACTG) (70) has issued preliminary guide-
lines on the management of lipid abnormalities in adults
with HIV/AIDS receiving antiretroviral therapy. Recom-
mendations for dietary management based on the National
Cholesterol Education Program (71) are outlined in
Table 3.
It should be noted, however, that there are limited data
to indicate the efficacy of dietary intervention on HAART-
 HAART treatment strategies

associated hyperlipidaemia. In one study, diet (plus exer-
cise) significantly reduced the cholesterol and/or
triglyceride concentration in eight of 44 people with
HIV/AIDS with HAART-associated hyperlipidaemia.
Drug therapy was required in the remaining patients to
decrease concentrations to within normal the range (72).
Moyle et al. (73) report a comparison of dietary advice ver-
sus diet plus pravastatin (a statin) in patients on protease
inhibitor therapy with cholesterol concentrations greater
than 6.5 mmol/L. Decreases in serum cholesterol of 4%
and 17% for diet and pravastatin, respectively, were
reported.
We investigated the relationship between dietary satu-
rated and total fat intake and serum lipids, insulin
resistance and body composition in 100 people with
HIV/AIDS including 44 reporting lipodystrophy (74). We
found no significant difference in dietary saturated and
total fat intake (adjusted for total energy intake) between
people with and without lipodystrophy. There was no sig-

Table 2. Current antiretroviral therapies available for use in Australia (dosage and food intake restrictions)
Chemical name Generic name Food restrictions Potential side effects(a)

Nucleoside analogue reverse transcriptase inhibitors

AZT Zidovudine Take with low fat meal Anaemia, nausea, headache, fatigue, neutropenia, neuropathy,
myopathy, diarrhoea, fever, anorexia, altered taste, dyspepsia,
increased liver function tests, weight gain
3TC Lamivudine No restrictions Nausea, fatigue, diarrheoa, vomiting, anaemia, anorexia,
abdominal pain, dyspepsia
AZT+3TC Zidovudine Take with low fat meal
Lamivudine
DdI Didanosine Take 0.5 hour before or 2 hours Hyperglycaemia, diabetes mellitus, hypertriglyceridaemia,
after a meal diarrhoea, abdominal pain, nausea, anaemia, hepatomegaly,
bloating, peripheral neuropathy, pancreatitis, elevated uric acid
DdC Zalcitabine Take on empty stomach Oral ulcers, dysphagia, abdominal pain, constipation,
hepatomegaly, peripheral neuropathy, pancreatitis, nausea,
diarrhoea, anorexia, myalgia, fatigue, weight loss
D4T Stavudine No restrictions Nausea, vomiting, abdominal pain, diarrhoea, pancreatitis,
increased liver function tests, peripheral neuropathy
1592U89 Abacavir No restrictions Nausea, headache, asthenia, rash
Generic name Food restrictions Potential side effects

Protease inhibitors
Saquinavir hard gel capsule Take with >54 g fat Diarrhoea, abdominal discomfort, nausea, hypoglycaemia,
increased creatine phosphokinase
Saquinavir soft gel capsule Take with >28 g fat As above
Amprenavir Avoid high fat foods Diarrhoea, nausea, rash
Ritonavir(b) Take with meals Nausea, vomiting, diarrhoea, abdominal pain, anorexia, taste
changes, dyspepsia, hyperlipidaemia, abdominal pain, elevated
liver function tests, triglycerides, cholesterol, creatine
phosphokinase and uric acid
Indinavir(b) Take 1 hour before or 2 hours after Nausea, vomiting, abdominal pain, diarrhoea, fatigue,
a meal, <5 g protein and <2 g fat nephrolithiasis, pharyngitis, taste changes
within the dose window. Require
>1.5 L of fluid/day
Nelfinavir Take with meal or light snack Mild to moderate diarrhoea, nausea, flatulence, abdominal pain
Kaletra Take with meal Diarrhoea, nausea, pancreatitis, hyperlipidaemia
Non-nucleoside reverse transcriptase inhibitors
Nevirapine No restrictions Nausea, fever, elevated liver function tests, weight loss, rash
Delaviridine No restrictions Abdominal pain and distension, anorexia, aphthous ulcers,
colitis, constipation, diarrhoea, intestinal inflammation, dry
mouth, pancreatitis, anaemia, rash
Efavirenz High fat meals to be avoided at Dizziness, insomnia, rash
dosing time
Ribonucleotide reductase inhibitors
Hydroxyurea(c) No restrictions Bone marrow suppression, aphthous ulcers, hair loss,
peripheral neuropathy
(a) Potential side effects are obtained from the manufacturers’ information.
(b) When indinavir is used with ritonavir, indinavir food (not fluid) restrictions are removed. Doses should be taken with food (as per ritonavir
specifications) to reduce nausea.
(c) Hydroxyurea augments the effect of other antiretroviral therapies (DDI, d4T and possibly other nucleoside analogue reverse transcriptase
inhibitors) without having a direct antiviral effect.

Australian Journal of Nutrition and Dietetics (2001) 58:4 229

HAART treatment strategies
Table 3. Preliminary guidelines for dietary management
of symptoms of lipodystrophy (adapted from 71)
Dietary intervention is recommended in the following
categories:
LDL cholesterol concentrations >4.2 mmol/L <5.0 mmol/L
without coronary artery disease and <2 risk factors. Consider
drug therapy if LDL cholesterol concentrations
≥5.0 mmol/L(a)
LDL cholesterol concentrations ≥3.4 mmol/L ≤4.2 mmol/L
without coronary artery disease and >2 risk factors(a)
LDL cholesterol concentration ≥2.6 mmol/L ≤3.4 mmol/L with
pre-existing coronary artery disease(a)
Total cholesterol >6.3 mmol/L or HDL cholesterol
<0.9 mmol/L
Triglycerides ≥2.2mmol/L ≤11.3mmol/L(a)
(a) Pharmaceutical therapy should be considered for people with
HIV-associated hyperlipidaemia with values in excess of these
ranges.
nificant correlation between dietary saturated or total fat
and the serum or body composition parameters measured.
We did, however, find that energy intake (in absolute
terms and when adjusted for weight, height and age) was
significantly higher in those people with HIV/AIDS
reporting lipodystrophy. We believe this relationship
(cause or effect) requires further investigation. This study
was cross-sectional. However, it would be prudent to fol-
low standard dietary procedures when an HIV patient
presents with metabolic abnormalities. It is important to
remember that dietary modifications are usually limited
by the requirements of the patient’s drug regimen as dis-
cussed previously. People with HIV/AIDS should also be
individually assessed for factors such as underlying HIV
symptoms (e.g. wasting), side effects of therapy, motiva-
tion and compliance prior to education.
Irwin et al. (75) found that both lower peripheral and
central fat were associated with regular weight training in
a group of people with HIV/AIDS with lipodystrophy. In
addition, a lower level of activity was associated with
hypertriglyceridaemia suggesting activity levels may be
related to at least that aspect of the syndrome. Roubenoff
et al. (76) suggest exercise may be useful in reducing vis-
ceral adiposity. They evaluated a 16-week exercise
program for ten men with HIV/AIDS with truncal obesity.
Total body fat decreased significantly, by an average of
1.5 kg (P < 0.01), and trunk fat declined most (1.1 kg,
P < 0.03). No adverse events were associated with the
exercise program. The authors concluded that both diet
and exercise should be factored into other studies of inter-
ventions for lipodystrophy.
Lipid-lowering agents
Gemfibrozil (a fibrate) has been used safely and has been
shown to reduce levels of cholesterol, and particularly
triglycerides, in people with protease inhibitor associated
hyperlipidaemia (72). Although it appears that only a small
number of people with HIV/AIDS will achieve concentra-
tions within the normal range, the effect of even modest
reductions in blood lipid concentrations on long-term
morbidity and mortality should be considered. Fenofibrate
is currently being investigated for use as a lipid-lowering
agent.
230 Australian Journal of Nutrition and Dietetics (2001) 58:4
The role of statins has not been established in people
with HIV/AIDS. Possible drug interactions between these
lipid-lowering agents and protease inhibitors have been
reported (77). Simvistatin is contraindicated for this rea-
son. Pravastatin is indicated as the drug least likely to
interact with protease inhibitor metabolism, and as
described above has been shown to decrease cholesterol
concentrations in patients with HAART-associated hyperl-
ipidaemia. Atorvastatin appears to be effective in
lowering lipid concentrations in this client group (72).
More safety data are required on the use of these agents
before their use is advocated.
Hypoglycaemic agents
Metformin (a biguanide) has been shown to decrease
plasma insulin and triglyceride concentrations, as well as
the ratio of visceral to total adipose tissue, and total vis-
ceral fat in people with HAART-associated
complications (78). Lactic acidosis is a reported side effect
and may limit is use (78).
Troglitazone (a thiazolidinedrone) was shown to be
effective in reducing glucose concentrations (79). How-
ever, it is not recommended as it is associated with hepatic
toxicity. In the same class of agents is rosiglitazone which
is currently being evaluated for its safety and efficacy.
Switching antiretroviral medications
Several studies have looked at the effect of switching
medications for patients with lipodystrophy. Changing to
a non-protease inhibitor containing regimen appears to
result in improvements in blood lipids (80,81) except where
the new regimen includes efavirenz (82,83). Varying effects
have been reported on visceral adiposity. No substantial
improvements in peripheral lipoatrophy have been shown,
possibly due to the role of nucleoside reverse transcriptase
inhibitors in this syndrome. A major concern with switch-
ing drug regimens is maintaining adequate viral control.
Anabolic agents
Trials are currently under way to investigate the use of
anabolic steroids for body composition changes in lipo-
dystrophy. One study suggested that the incidence of body
habitus changes in people with HIV/AIDS who were
receiving steroids (testosterone, nandrolone decanoate,
oxandrolone or growth hormone) was significantly lower
than that reported elsewhere (84). However, the degree of
viral control was lower in this group and this may have
confounded the results. Some anabolic preparations are
associated with increases in insulin resistance and serum
lipids (85), although these changes have not been shown
with injectable preparations such as nandrolone
decanoate (86). Recently, we investigated the effect of high
dose nandrolone decanoate on serum and body composi-
tion parameters in HIV-positive men with pre-existing
lipodystrophy and showed no significant effects on serum
lipids, glucose and insulin over an eight-week period (87).
Waist circumference did not change. However, calf cir-
cumference and mid-upper arm circumference increased.
These changes were viewed as favourable by the partici-
pants who felt the increases in arm and leg size gave a
more balanced body morphology.
Growth hormone has been reported to significantly
reduce visceral adiposity in lipodystrophy (88–90). It is

unknown whether growth hormone further decreases
peripheral fat stores or increases blood lipid concentra-
tions in people with HIV/AIDS. Also, positive effects on
visceral adiposity seem to be lost once treatment has
ceased. The cost of this agent may limit access in many
centres. Further research is necessary to assess particular
interventions with respect to efficacy, drug interactions
and side effects.
Osteoporosis
A connection between the use of protease inhibitors and
decreased bone mineral density has been proposed. Luna
et al. (91) found decreased total body bone mineral density
in a group of 17 HIV-positive men receiving HAART.
More recently, Tebas et al. (92), examining whole body,
lumbar spine and proximal femur bone mineral density,
reported the prevalence of bone diseases such as oste-
oporosis was 50% in patients taking protease inhibitors.
The risk of osteoporosis in subjects treated with the pro-
tease inhibitor was found to be twice that of people with
HIV/AIDS not on protease inhibitors. These researchers
also found a higher ratio of central to appendicular adi-
pose tissue in the group treated with protease inhibitor but
this was not found to correlate with bone mineral density,
suggesting this to be an independent side effect of
HAART. The role of diet has not been investigated in this
context. Nevertheless, it would be prudent to ensure ade-
quate calcium intake and, where possible, weight-bearing
exercise by this patient group.
Assessing patients with HIV in the HAART era
Figure 1 shows the major reasons for referral of people
with HIV/AIDS and suggested management strategies.
Weight and body composition
A history of weight changes and any changes in body
composition should be documented. In particular, loss of
peripheral or facial and gluteal subcutaneous fat and vis-
ceral adiposity should be noted as these are indicative of
lipodystrophy. Body composition should be quantitatively
assessed on a routine basis (about every three months)
particularly prior to any changes in antiretroviral therapy.
Bioelectrical impedance is useful for assessing fat free
mass provided an appropriate prediction equation is
used (93). Skinfold anthropometry is also useful for detect-
ing site-specific changes in fat distribution. Multiple sites
should be measured, but we have found the subscapular to
tricep skinfold ratio particularly useful in predicting
lipodystrophy (94). It is important to have serial measure-
ments of body composition in order to distinguish
between fat loss which may be related to
lipodystrophy (95) and loss of fat free mass associated
with HIV wasting. A dual energy X-ray absorptiometry
scan to assess bone mineral content as well as body com-
position may be useful to assess potential osteoporosis.
Assessing dietary intake and social situation
Social supports, cooking skills, and financial situation
should be assessed in addition to the adequacy of dietary
intake. Long-term survivors with HIV may have lost most
of their social network to the illness and be relying on
social security benefits. Although the role of diet in treat-
ing lipodystrophy is unclear, focus should be given to the
type of dietary fat consumed and its modification if neces-
HAART treatment strategies
sary. However, the practicalities of cooking skills and the
person’s living situation may take priority, particularly, in
advanced disease where there is less concern over the
long-term nutritional adequacy.
Assessing energy requirements
Although there is some discrepancy in the literature (dis-
cussed in the previous article) (1), resting energy
expenditure and total energy expenditure (96) appear to be
elevated in this population group. Energy intake has also
been shown to be high in this patient group (74). Energy
needs are 10% to 15% higher than that predicted by stand-
ard prediction equations and this should be taken into
account when estimating energy requirements.
Biochemistry
In addition to any standard nutritional markers indicated
by symptoms or disease, fasting measures of serum glu-
cose, insulin, total and HDL cholesterol, and C-peptide
should be measured routinely (95), particularly prior to and
during treatment with antiretroviral therapy. In addition
the CD4 T cell count and viral load should be documented
as markers of HIV disease progression along with the
length of HIV infection. These may effect the aggressive-
ness of treatment decisions.
Medications
Current and previous antiretroviral regimens should be
documented and the restrictions associated with these
medications incorporated into the dietary management
plan. Other medications and drug-nutrient interactions or
dietary restrictions should be considered.
Other risk factors
Documenting other cardiovascular or diabetic risk factors,
such as smoking, family history and whether or not the
patient exercises, may impact on the management plan.
Although the metabolic abnormalities are usually associ-
ated with lipodystrophy, traditional risk factors can also
result in lifestyle-related diseases in this population.
Conclusion
Nutritional management of people with HIV/AIDS has
become an increasingly complex task. For dietitians
working with this client group, knowledge of the current
nutritional issues is essential to provide appropriate nutri-
tion education and support. This paper has discussed
current management strategies for managing some of the
nutritional issues prevalent in people with HIV/AIDS in
the HAART era. For those who may already have
advanced HIV disease prior to commencing therapies, or
for those people with HIV/AIDS who are not responding
to, or cannot take, antiretroviral medications, it is also
important to be aware of conventional nutritional issues
concerning people with HIV/AIDS. It is crucial that die-
tary intervention is individualised to maintain and/or
maximise the nutritional status and quality of life of each
person positive for HIV.
Australian Journal of Nutrition and Dietetics (2001) 58:4 231
HAART treatment strategies

Acknowledgment 5. Dowling S, Mulcahy F, Gibney MJ. Nutrition in the management of

The assistance of Sylvia Bridle, Pharmacist, The Albion Street
Centre, in preparing the table referring to pharmacological
agents is greatly appreciated.
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Books received
Nutrition and Huntington's disease, a practical guide
van Broekhoven-Grutters E, Gaasbeek D, Veninga-Verbaas M, Atlant Zorgroep, Apeldoorn, 2000, 70 pages, $30.00,
ISBN 90-805882-1-0
Kids food health 1: nutrition and your child's development: the first year
McVeagh P, Reed E, Finch Publishing, Sydney, 2001, 202 pages, $21.95, ISBN 1-876451-14-9
Kids food health 2: nutrition and your child's development: from toddler to preschooler
McVeagh P, Reed E, Finch Publishing, Sydney, 2001, 170 pages, $21.95, ISBN 1-876451-15-7
Kids food health 3: nutrition and your child's development: from school-age to teenage
McVeagh P, Reed E, Finch Publishing, Sydney, 2001, 204 pages, $21.95, ISBN 1-876451-16-5
Nutrition in the infant—problems and practical procedures
Preedy V, Grimble G, Watson R, editors, Science Blackwell Asia, London, 2001, 447 pages, $299.20, ISBN 1-90015-
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Manual of dietetic practice. Third edition
Thomas B, editor, Blackwell Science Asia, London, 2001, 758 pages, $210.10, ISBN 0-632-05524-3
Artificial nutrition support in clinical practice
Payne-James J, Grimble G, Silk D, editors, Greenwich Medical Media, London, 2001, 798 pages, $440.00, 1-90015-
197-9
FoodScan 2000
Andromeda Educational Software, Andromeda Educational Software, Elwood, 2000, 46 pages plus CD ROM,
$690.00
Live stronger, live longer
Awerbuch M, McGraw-Hill, Roseville, 2001, 230 pages, $28.95, ISBN 0-07-471087-7
Manual of nutritional therapeutics
Alpers D, Stenson W, Bier D, Lippincott Williams & Wilkins, Philadelphia, 2002, 644 pages, $101.20, ISBN 0-7817-
3122-4

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