Issue Contents  HIV, drugs and diets Research update Slow progress against HIV Anti-HIV treatments How HIV works Pregnancy and AZT Problems Immune system boosting Affordable and effective? Developing new drugs Nutrition guidelines Eat healthily, stay healthy Nutritious and easy to eat What is a balanced diet? Helping with difficulties For women and children Community coping Safe food preparation Learning through games AIDS: everyone's task Sample "Everyone's task" cards Sample "Community' cards Learning about AIDS Letter Resources

HIV, Drugs and diets

Articles in this issue of AIDS Action highlight two areas of interest for people living with HIV or AIDS and those involved in caring for them - nutrition and anti-HIV treatments. The article on pages 2 and 3 summarises new developments in treatments for tackling HIV. The author emphasises that, although researchers are making some progress, fully effective and affordable drugs against HIV have not been developed yet.

Prevention and treatment for common opportunistic illnesses are still the most important strategies against HIV, especially now that TB causes more deaths in HIV-positive people than any other infection.  Good nutrition also plays a major role in maintaining health (see pages 4 and 5). It is often possible to make low-cost meals that are more nutritious, tastier and easier to eat for people who are unwell.  On page 8, a reader in Tanzania explains how she successfully introduced the group exercise 'Understanding HIV' which was described in issue 27. This issue features another educational game which is popular in Chile, and which could be adapted for use in other languages and situations.

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In this issue   Anti-HIV drugs Pages 2 and 3 Nutrition and HIV Pages 4 and 5 AIDS education Pages 6 and 7

Slow progress against HIV

We are still a long way from discovering a 'cure' for HIV infection. AIDS Action highlights problems in developing new treatments.

There are three types of treatment for people with HIV. These aim to:

	prevent the virus from reproducing
	strengthen or 'boost' the immune system
	cure opportunistic infections.

Anti HIV treatments
One type of anti-viral drug aims to prevent or slow down viral reproduction in human cells (see box below). The drugs have a similar chemical structure to human DNA. This means that the virus bonds with the drug rather than the DNA, and so cannot use the DNA to reproduce itself.

The most widely used anti-viral drug is still AZT, or zidovudine. AZT has been in use since 1985 and is manufactured by Wellcome, under the brand name of Retrovir. Its benefits are limited when taken alone. The 1993 Concorde trial showed that AZT does not benefit people who are still healthy.

A number of other anti-viral drugs have been licensed in different countries for use alone (monotherapy) or in combination with AZT (combination therapy). They include ddl (didanosine), ddC (zalcitabine) and d4T (stavudine). 

In September 1995 an international drug trial called Delta proved that a combination of anti-viral drugs is much better at delaying the development of HIV-related infections and death than AZT alone. The two-year trial compared the health status of people with HIV taking 'combination therapy' (AZT plus ddl or AZT plus ddC) with another group taking AZT alone. Ten per cent of participants were women. Results show that, compared with taking AZT alone, the likelihood of dying for people taking combination therapy was reduced by almost 40 per cent. The benefits were greatest for participants who had never taken an anti-viral treatment before. However, disease progression was not affected for those starting combination therapy after taking AZT alone for several months.

Pregnancy and AZT 
Two recent studies show that AZT treatment for HIV-positive pregnant women before and during delivery, and for their newborns, can reduce HIV transmission to the baby. A study in the USA called ACTG 076 showed that the chance of mother-to-baby HIV transmission was reduced by two-thirds when AZT was given during the last 20 weeks of pregnancy, intravenously during childbirth and to the newborn child.

However, there are many unanswered questions. The studies, in Europe and North America, involved only a small number of infants. The results may not apply to all HIV-positive women. AZT is toxic, and its long term effects on women and newborn infants are not known. Only one-third of infants born to women with HIV are HIV-infected themselves, therefore many uninfected babies could be exposed needlessly to AZT. Although some pregnant women with HIV in Europe and North America are taking it, more follow-up is necessary. Following the Delta trial it seems likely that women who choose to take anti-viral treatment during pregnancy will be recommended combination therapy rather than AZT on its own.

Problems
There are several disadvantages to anti-viral drugs. It is now clear, for example, that the virus quickly becomes resistant to AZT. All these drugs are toxic and cause side effects such as nausea, anaemia and muscle wasting, and sometimes other serious illnesses. These side effects are more severe at higher doses and more likely to appear in people with advanced HIV infection. For people without symptoms there are fewer side effects but the long-term impact on their health has not been studied. People taking anti-viral drugs need access to regular and expensive monitoring tests which require laboratory facilities and trained staff. For example. blood tests are needed to detect anaemia, as well as high enzyme levels in the blood which can lead to serious illnesses such as pancreatitis. Taking the drugs without medical supervision can do more harm than good. Other types of anti-viral drugs are still in very early stages of development. Studies are taking place to investigate drugs called 'protease inhibitors' such as saquinavir. Protease inhibitors aim to deactivate the special HIV enzyme which enables attachment to the white blood cells. Scientists hope that they will be less toxic than drugs such as AZT and ddl. Trials are in preliminary phases and there is no evidence at present to suggest that they prolong life or delay the development of HIV-related illnesses.

How HIV works After someone has been infected by HIV the virus begins to multiply rapidly in the body. The virus attaches itself to the surface of special white blood cells involved in fighting infections (CD4 cells). Then, after entering a CD4 cell, the virus bonds with the cell's DNA. DNA is the human genetic material which enables cells to reproduce. This means that when the cell tries to reproduce itself, it is forced to produce more virus instead of another human cell, and is also destroyed in the process. At first, the person's immune system is able to kill many of the CD4 cells which become infected with HIV. However, the virus is never totally destroyed. It continues to reproduce and eventually die immune system becomes unable to destroy the large numbers of HIV-infected cells. As the number of uninfected CD4 cells declines, the immune system becomes less able to fight illnesses.

Developing new drugs  New treatments need to be tested for safety and effectiveness in several stages, before they can be licensed for commercial manufacture. The research process can take many years and involves:   laboratory studies to assess the impact of the drug on the virus itself research on animals to study effects on health and the immune system  small scale studies/trials with volunteers to test for side effects and impact on health and immune system large scale studies with many people for at least a year to prove safety and effectiveness.    Reports in the media about the discovery of a cure often raise false hopes because all the trial stages have not been completed. There is much debate about whether drugs should be made available before the final stage is completed, because the need for treatments is so great. Some drug companies have run lotteries to select trial participants, because so many people volunteer to take part.

Some studies have shown that HIV itself can cause severe weight loss. This can take the form of muscle wasting where muscle and other protein stores are used up, in addition to fat reserves. Healthy people with HIV infection are recommended to eat as much as possible of a balanced diet. Some people like to take special vitamin and 'energy-rich' supplements. However, these are costly and are not necessary. It is especially important for people with HIV to have enough proteins and micronutrients such as vitamin A and iron. Vitamin A plays a key role in keeping the immune system healthy. Studies show that children who lack vitamin A have more frequent diarrhoea and respiratory infections.

Nutritious and easy to eat 

Some foods can be made more nutritious and easy to digest. Porridge can be made more energy-rich by adding nuts or oil, by replacing some of the water with fresh milk or coconut milk, or by adding mashed fish, dark green or orange fruits and vegetables or fruit juice. Traditional weaning foods can be adapted for people who are sick or having difficulty in eating. Porridge can be made thinner, easier to swallow and more nutritious by 'fermenting' or 'malting'. 

Fermentation turns some of the starch in the flour into acidic products. This sours the porridge, making it thinner with a higher concentration of nutrients, and also increases the absorption of some nutrients such as iron and zinc. Bacteria which cause diarrhoea are less likely to grow in soured than in ordinary porridge. One way to make soured porridge is to mix flour with water so the mixture is liquid, leave it to ferment overnight, and then cook as normal. The flour and water mixture becomes more sour the longer it is left. Cooked porridge can also be soured by adding a spoonful of previously fermented porridge. 

Malting means allowing cereal grains to germinate (start sprouting) by soaking them in water for two days, spreading them out on sacks and covering them with a damp cloth. They are then left in the dark and kept damp for two to four days. After malting, the grains should be washed and dried before they are roasted, fermented, or pounded into flour. It is important not to use grains which have developed mould because this can become toxic.

Helping with difficulties
What is good for a healthy person is good for a sick person. However, people who are sick with HIV-related infections may need a diet that helps them to:

	increase their appetite and take in enough nutrients
	help the digestive system cope with and recover from diarrhoea
	recover weight and strength lost during illness.

During illness

It is important for the person to continue to eat as much as possible. The food should be easy to eat and easily absorbed. 

Mouth sores: the person may prefer to eat food that does not need to be chewed, for example milk, porridge, soup, or mashed fruit or vegetables. It is important not to make the food too watery because this reduces the amount of nutrients. Cool food can be more soothing than hot food. Avoid using spicy and peppery foods. 

Poor appetite: it is best for the person to eat small amounts more often than usual. Use a variety of foods that the person likes. If they feel nauseous avoid strong smelling foods and cooking smells that linger. 

Diarrhoea: this damages the gut so fewer nutrients are absorbed. Damaged intestines need easily digestible foods such as porridge or soups. In some cases fatty or oily foods can worsen diarrhoea because the gut cannot absorb them. Milk can also cause poor absorption in a few people. Damaged intestines are sometimes intolerant to lactose, the sugar found in milk. If the diarrhoea persists the person can consider excluding milk from their diet to see whether the diarrhoea lessens. Other nutritious foods should be taken instead. Antibiotics can also worsen diarrhoea. During illness, especially diarrhoea and vomiting, make sure the person drinks extra fluids to prevent dehydration, such as thin porridge, coconut water, fruit juices, thin vegetable soups or yoghurt-based drinks. Oral rehydration salts solution can be taken if available.

Quick recovery 
When an acute infection passes it is important for the sick person to have extra food in order to repair the gut, rebuild muscles and replace the body's store of nutrients that has been used up during the illness. This extra food is needed until the body has regained weight. The person should try to eat one extra meal each day, and it is good to have extra food at each meal.

Staying well 
When the person is feeling stronger, they should try to continue eating well, including foods that have not been eaten during illness.

For women and children 

All pregnant women need extra nutrients, especially if they are anaemic (iron deficiency). It is important for all pregnant women to have enough vitamin A through eating dark green leaves or orange fruits and vegetables, and, if available, liver or egg yolk. A study in Malawi has indicated that babies born to HIV-positive women with vitamin A deficiency are three or four times more likely to have HIV than those born to HIV-positive women with normal levels of vitamin A. It is thought that this is because vitamin A is important for the immune protection provided by the mother and prevents HIV from passing across the placenta from mother to child. This finding is being investigated further. 

Breastmilk is the best form of nutrition for every infant, especially during diarrhoea. If the mother has decided not to breastfeed, for example due to severe HIV-related illnesses, ensure that the child is fed adequately using a cup and spoon (see AIDS Action 27). After an attack of illness give older children an extra meal until they are at least the same weight as before the illness.

Community coping

It is often difficult for people living with HIV and their carers to eat well. Illness in a family is often linked with poverty, because, for example, adults may be too sick to cultivate land or to earn income. 

Food aid Some NGOs provide food aid to families. However, many people in poor communities are badly nourished or sick, not just those with HIV. Providing food only to people known to have HIV draws attention to them when they may prefer to keep their HIV status confidential. Some NGOs have chosen to provide food through schools and mother and child health or TB clinics. One NGO in Tanzania provides food to families where the household has an orphan or is headed by a child, elderly person or woman with no land. Decisions about who receives food are made by local committees. 

Maintaining food production It is important to work with local people and agricultural programmes to avoid food shortages caused by a decline in farming. Providing technical support, such as training on crop diversification and livestock management, transport, storage and marketing, or providing credit can lessen food shortages and increase income. Some organisations work with legal associations to ensure land inheritance for widows and children who would otherwise lose their land on the death of a partner or parent.

Home care Home care and counselling advice should include information about nutrition. Some organisations are running courses for people with HIV and their carers about improving nutrition with locally available products. 

Sources: Semba R, 1994, 'Maternal vitamin A deficiency and mother-to-child transmission of HIV-1', The Lancet, vol. 343, no 8913, p 1593-1597. 

'Malnutrition and chronic diarrhoea - nutrition guidelines' (draft), 1995, City Health Department, Mutare, Zimbabwe.

Safe food preparation 
People with HIV are vulnerable to infection. Clean food preparation and storage can reduce the spread of germs, including those that cause diarrhoea.
 

	Cook food until it is thoroughly heated, and heat liquids until they start to bubble, to kill any germs.
	Avoid storing cooked food for more than 24 hours. Thoroughly reheat food that has been kept more than two hours after being cooked. Store water and food in clean, covered containers.
	Wash fruits and vegetables with clean water.
	Use safe, clean water for drinking and preparing food.
	Wash hands with water and soap or ashes before and after food preparation or eating food.
	Use a clean cup to feed infants. Feeding bottles and teats are difficult to keep clean.

AIDS: everyone's task

Organisations working in community health development have a key role in AIDS education. EPES, a community health group working in Chile, describe how they developed the game on page 7. 

When we started talking about AIDS we realised that we did not have any teaching materials to share knowledge with people in a participative way. So in 1989 we developed a board game called Learning about AIDS: everyone's task. The game is based on local people's experiences and aims to: 

	provide basic information on HIV/AIDS
	encourage discussion about ideas, beliefs and myths about AIDS
	give opportunities for open exchange of opinions and views about sexuality and AIDS
	promote awareness of how AIDS affects the community and the need for HIV prevention.

Everyone is affected by AIDS and has a role to play in fighting the epidemic. Every community is able to respond in a supportive, caring and effective way. But people need opportunities to discuss the issues and think about their attitudes and feelings. 

The game uses two sets of cards: 72 'Everyone's task' cards with questions on HIV transmission and prevention; and 35 'Community' cards describing possible situations in the community where problems and issues about HIV and AIDS could arise (see examples). The issues are discussed in a booklet which accompanies the game. It is essential to have a skilled facilitator who is aware of the issues that arise when talking about HIV and sexual health. People play the game in pairs using a dice. Each player in turn moves their counter forward the number of squares on the board shown on the dice. If the counter lands on a square marked with a number the person picks up a card and answers it. When a counter lands on a 'Community' card square the group discuss the issue. These cards do not have 'right' or 'wrong' answers. The game was designed with a group of people involved in education or living with AIDS and is based on real life experiences. Each group who uses the game can change it for local use. For example, a group of students at the local university played the game during a special event. They made a large-scale version on a football pitch, built life-size models of the community buildings and made a giant dice. Groups in other countries could develop a new set of issues and questions for the players to consider.  The game can be a useful part of an HIV prevention strategy which includes three key elements: relevant information and education; access to services; changing social attitudes to enable every individual to develop their own sexuality healthily and safely. The game both provides information and challenges the players to think about all the issues in their community.

 
Sonia Covarrubias, EPES, Casilla 360-11, Nuñoa, Santiago, Chile.


Sample 'Everyone's task' cards:

	What is AIDS?
	What is an 'immune system'?
	Are HIV symptoms the same in men and women?
	Name three ways in which someone can become infects with HIV.
	Name various ways of reducing the risk of HIV transmission.
	Does everyone with AIDS die because this illness?
	Should someone with HIV continue in his or her job?
	True or false: married people do not get HIV.
	Can using drugs or alcohol contribute to risk of HIV transmission?
	Do birth control methods prevent HIV transmission?

‘Understanding HIV: shall we try it?
After studying the training exercise ‘Understanding HIV’ explained in issue 27 of AIDS Action we decided to introduce it into our AIDS education workshops. Each time we carry out the exercise it has a deep impact on the group. Once the group has really understood how to proceed in the game each step brings UP important issues and feelings which are very helpful in strengthening AIDS awareness.

Because our teaching team is involved in providing HIV/AIDS services both at a counselling centre and in the community we find the reactions during the game parallel  those encountered in the reality of every day. It is a good learning exercise and helps us move from theory to experience if used during an education workshop. We are ready for more innovative techniques to keep AIDS education alive! 

Dr Brigid Corrigan, Pastoral  Activities and services for AIDS, Dar es Salaam, Tanzania. 

Ed note: We like to hear from readers about their views on the articles and activities in AIDS Action. Please write and tell us what you would like to read about and how you use AIDS Action in your work.

Resources

Nutrition for developing countries is a practical guide for nutrition workers working in the community and gives basic facts on nutrients and food.
Available for £3.95 from TALC, PO Box 49, St Albans, AL1 4AX, Herts, UK.

What has AIDS to do with agriculture? is a booklet for agriculture workers and planners in HIV affected areas. 
For price and availability write to Publications Division, FAO, Viale delle Terme di Caracalla, 00100, Rome, Italy.

Caring for people with AIDS at  home provides information for teaching  families to provide nursing care to people with HIV including nutrition, hygiene, pain relief and treatment of main opportunistic infections and information on HIV transmission and prevention.
Available for Sw.fr.5.00 in English, French, Portuguese and Spanish (Arabic in preparation available from International Federation of Red Cross and Red Crescent Societies, PO Box 372, CH 1211Geneva 19, Switzerland.

Newsletters

AIDS Treatment Update is a monthly newsletter providing information about new clinical trials and treatments that are available mostly in Europe and North America, but can be useful for health workers and researchers in developing countries. Available for £40 per year from NAM, Unit 52, The Eurolink Centre, 49 Effra Rood, London SW2 IBZ. UK. NAM also produce a twice-yearly A-Z of treatments and opportunistic infections, the HIV & AIDS Treatments Directory. AIDS Treatment News is published 24 times a year. It provides information on experimental and standard treatments for HIV disease, mostly aimed at North America and Europe.  Available for US$120 per year or US$60 for six months from AIDS Treatment News, P 0 Box 41 1256, San Francisco, CA 94 141 , USA .

There are many groups set up by people living with HIV and AIDS providing support on treatment issues and care, including nutrition.
For more information about local groups contact Global Network of People Living with HIV and AIDS (GNP+), PO Box 1 1726, 1001 GS Amsterdam, The Netherlands or International Community of Women living with HIV & AIDS, PO Box 2338, London W8 4ZG, UK.

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