Globally, there are an estimated 34 million people infected with HIV and almost 70% of those live in sub-Saharan Africa (1). Weight loss and undernutrition are common in patients with HIV and can accelerate disease progression and increase morbidity and mortality (2). Even after patients start antiretroviral treatment, poor nutritional status is highly predictive of mortality (3,4). In addition to the consequences of food insecurity frequently present in communities affected by HIV, three clinical factors principally contribute to undernutrition in patients with HIV: inadequate intake (due to lack of appetite or difficulties eating due to mouth ulcers), malabsorption (due to diarrhoea or damage to the intestine (5,6) and increased energy expenditure (patients infected with HIV, even if seemingly well and without opportunistic infection, have a resting metabolic rate 10% higher than uninfected adults) (6-10).

Antiretroviral treatment interrupts the replication of HIV and results not only in clinical and immune function improvement but rapid and significant weight gain, provided that the diet contains adequate energy, protein and micronutrients to enable nutritional recovery (11-14). However, reduced body mass index is still predictive of mortality even with antiretroviral treatment, and highlights the value of appropriate nutritional monitoring and support in addition to antiretroviral medications (2). Furthermore, reduced food intake can reduce the efficacy of antiretroviral treatment regimens, as some drugs may not be properly absorbed or can cause significant side effects if not taken with adequate food (15,16).

A review by WHO in 2005 recommended energy intake should be increased by 10% for HIV-infected but asymptomatic patients relative to usual dietary recommendations, and by 20-50% for those recovering from opportunistic infections, keeping the proportion of protein between 12 and 15% of total energy intake, as there is no evidence that higher protein intake is beneficial (17). In settings where food is scarce or the quality of food is poor, it may not be possible to achieve this increase in energy intake without supplementation.

Although there are few studies of the optimal composition of a macronutrient supplement for patients with HIV, nutrition interventions including food packages and macronutrient and/or micronutrient supplements have been successfully integrated into antiretroviral programmes in sub-Saharan Africa (18,19), either through the provision of staple foods or via replacements such as ready-to-use foods (nutrient-dense supplements usually in the form of lipid-based spreads with a range of micronutrients), or corn-soy blends or fortified blended foods (20).

While limited, evidence suggests that those most likely to benefit from macronutrient supplementation are certain populations of undernourished patients with more advanced disease, particularly in settings where food security may be an issue (21,22). Studies among HIV-infected adults in Haiti, Kenya, Malawi and Zambia have demonstrated significant positive effects of macronutrient supplementation on adherence to antiretroviral medication, weight gain and CD4 counts (23,24-26). Other factors to consider include the type, quantity and duration of supplementation, household food security and food sharing, as well as outcomes of interest, such as body weight and clinical measures of HIV infection, and potential effects on economic productivity, comorbidities and quality of life (27). Challenges to the implementation of supplementation programmes include agreeing on exit criteria for stopping supplements, sustainability, avoidance of dependency and equity in communities where food insecurity is also common in the general population. Cost-effectiveness analyses can further help determine which populations are most likely to benefit from supplementation as well as how to organize the distribution of supplements in the most efficient and sustainable manner (28).

Further research on these and other areas is needed to understand the benefits of various supplementation strategies in conjunction with antiretroviral treatment, particularly in settings where HIV infection and food insecurity are widespread and frequently overlap. While population-wide solutions to improve food insecurity and nutritional status of the entire community are relevant, the need for targeted supplementation of HIV-infected individuals may still remain, not only to improve nutritional status but also enhance antiretroviral adherence and outcomes.

* CD4 counts measure the number of CD4 cells or T-helper cells in a person’s blood. CD4 cells are a type of white blood cell that fights infection. Along with other tests used in HIV/AIDS, CD4 counts provide an indication of how strong a person’s immune system is, indicate the stage of disease, guide treatment and predict how the disease may progress.

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Conflict of interest statements were collected from all named authors and no conflicts were identified.