Case Study : HIV/AIDS
Alastair Duncan and Clare Stradling Andy is a 48-year-old Caucasian male living in an urban area in the United Kingdom. He has always been fit and healthy, although, for the past 6 months, gives a history of feeling tired all the time. Four weeks ago he was diagnosed with HIV by his GP. The next day he attended the HIV clinic at the hospital for counselling and phlebotomy, and saw the HIV consultant 2 weeks ago. During this appointment Andy was commenced on antiretrovirals. It is the standard clinical protocol that all patients newly diagnosed with HIV, and all patients commencing on antiretrovirals for the first time are referred for dietetic review. Andy was referred by the consultant, and attends the dietetic outpatient clinic today.
Assessment
Domain
Anthropometry, body composition and functional Weight 91.9 kg
Height 1.78 m
Weight has been stable at 86 kg past 10 years
Left arm MUAC 41.5 cm
Triceps skinfold 28 mm
Waist 109 cm
Hips 103 cm
Biochemical and haematological
(Reference range) CD4 90 cells/mL (300–1000)
HIV viral load 880,050 particles/mL (<20)
Sodium 139 mmol/L
Potassium 4.1 mmol/L
Creatinine 85 µmol/L
eGFR 98 mL/min
Hb 121 g/L
Liver function tests
ALT 12 IU/L (<40) ALP 48 IU/L (40–129) GGT 60 IU/L (7–33) Total cholesterol 6.1 mmol/L Triglycerides 5.2 mmol/L Glucose 6.9 mmol/L Vitamin D 41 nmol/L (>59)
NB: Results from a non-fasting phlebotomy 4/52 ago
Clinical No previous medical history of note
Physical examination – nothing of concern
Andy continues to report feeling tired all the time
BP 136/89 mmHg
Medication
Antiretrovirals D – darunavir, ritonavir, tenofovir and emtrcitabine (to be taken together at bedtime with a snack)
Loperamide and cyclizine in case he experienced side effects because of the antiretrovirals but has not needed to use them
No other medicines or supplements
Appetite very good
No oral or gastrointestinal problems
Diet 24-h recall
Breakfast 06:30
4 slices white toast (4 × 27 g) with margarine (4 × 7 g) and marmalade (4 × 15 g)
250 mL orange juice (tetrapak carton)
2 mugs instant coffee with semi-skimmed milk (2 × 40 g) and 2 tsp sugar (2 × 10 g)
Mid-morning snack 09:30
1 mug instant coffee with semi-skimmed milk (40 g) and 2 tsp sugar (10 g)
6 digestive biscuits (6 × 13 g)
Lunch 12:00
Ham sandwich made at home, 2 slices white bread (2 × 36 g), ham (46 g), mayonnaise (15 g), ½ tomato sliced (40 g)
1 banana (100 g)
500 mL blackcurrant squash (50 g concentrate)
Mid-afternoon snack 15:00
1 mug tea with semi-skimmed milk (40 g) and 1 tsp sugar (4 g)
4 digestive biscuits (4 × 13 g)
Evening meal 17:30
Cottage pie (own-brand economy range ready meal single portion) (400 g)
1 Muller light yoghurt (175 g)
Supper 20:00
500 mL red wine from a box pack
Food frequencies
Fruit – 1 portion per day plus 1 glass juice
Vegetables – 1 portion per day
Oily fish – 1 portion per week
Alcohol
30–40 units/week, boxes of wine, and spirits, mostly during the weekend
Meal patterns
Always eats 3 meals per day when working, and takes food with him when on a night shift
Often skips meals at weekend, usually when clubbing
Environmental, behavioural and social Andy is single, lives alone in a council flat, works early, late and night shifts as a cleaner, and earns minimum wage. He seeks out bargains and buys from the economy range when food shopping. He has few friends and does not keep in touch with his family. He goes clubbing 3–4 times monthly and takes recreational drugs (usually crystal meth, mephedrone, or speed) at this time. He goes to the pub on Fridays, Saturdays and Sundays and admits to getting drunk sometimes. He says he is lonely but not depressed
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Questions:
1. What is the nutrition and dietetic diagnosis?
2. How would you calculate protein and energy requirements for an HIV patient?
3. What measures of anthropometry are routinely used in HIV care, and what is their utility?