AIDS and Behavior

, Volume 17, Issue 6, pp 2011–2021 | Cite as

Impact of Protein Supplementation and Care and Support on Body Composition and CD4 Count Among HIV-Infected Women Living in Rural India: Results from a Randomized Pilot Clinical Trial

  • Adeline NyamathiEmail author
  • Sanjeev Sinha
  • Kalyan K. Ganguly
  • Padma Ramakrishna
  • P. Suresh
  • Catherine L. Carpenter
Original Paper


Body composition in HIV-infected individuals is subject to many influences. We conducted a pilot 6-month randomized trial of 68 women living with AIDS (WLA) from rural India. High protein intervention combined with education and supportive care delivered by HIV-trained village women (activated social health activist [Asha] life [AL]) was compared to standard protein with usual care delivered by village community assistants (usual care [UC]). Measurements included CD4 counts, ART adherence, socio-demographics, disease characteristics (questionnaires); and anthropometry (bioimpedance analyzer). Repeated measures analysis of variance modeled associations. AL significantly gained in BMI, muscle mass, fat mass, ART adherence, and CD4 counts compared to UC, with higher weight and muscle mass gains among ART adherent (≥66 %) participants who had healthier immunity (CD4 ≥450). BMI of WLA improved through high protein supplementation combined with education and supportive care. Future research is needed to determine which intervention aspect was most responsible.


Nutrition AIDS in rural women ART Protein Body composition 



Support for this research was provided by Grant MH82662 from the National Institute on Mental Health.


  1. 1.
    English RM, Badcock JC, Giay T, Ngu T, Waters AM, Bennett SA. Effect of nutrition improvement project on morbidity from infectious diseases in preschool children in Vietnam: comparison with control commune. BMJ. 1997;315(7116):1122–5.PubMedCrossRefGoogle Scholar
  2. 2.
    Mahlungulu S, Grobler LA, Visser ME, Volmink J. Nutritional interventions for reducing morbidity and mortality in people with HIV. Cochrane Database Syst Rev. 2007;(3):CD004536.Google Scholar
  3. 3.
    Mangili A, Murman DH, Zampini AM, Wanke CA. Nutrition and HIV infection: review of weight loss and wasting in the era of highly active antiretroviral therapy from the nutrition for healthy living cohort. Clin Infect Dis. 2006;42(6):836–42.PubMedCrossRefGoogle Scholar
  4. 4.
    Tang AM, Forrester J, Spiegelman D, Knox TA, Tchetgen E, Gorbach SL. Weight loss and survival in HIV-positive patients in the era of highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2002;31(2):230–6.PubMedCrossRefGoogle Scholar
  5. 5.
    WHO. Physical status: the use and interpretation of anthropometry. World Health Organization. 1995.Google Scholar
  6. 6.
    Clark RH, Feleke G, Din M, et al. Nutritional treatment for acquired immunodeficiency virus-associated wasting using beta-hydroxy beta-methylbutyrate, glutamine, and arginine: a randomized, double-blind, placebo-controlled study. JPEN (J Parenter Enter Nutr). 2000;24(3):133–9.CrossRefGoogle Scholar
  7. 7.
    de Luis D, Aller R, Bachiller P, et al. Isolated dietary counselling program versus supplement and dietary counselling in patients with human immunodeficiency virus infection. Med Clin (Barc). 2003;120(15):565–7.CrossRefGoogle Scholar
  8. 8.
    Tsai AC, Hung KJ, Weiser SD. Is food insecurity associated with HIV risk? Cross-sectional evidence from sexually active women in Brazil. PLoS Med. 2012;9(4):e1001203.PubMedCrossRefGoogle Scholar
  9. 9.
    Weiser SD, Leiter K, Bangsberg DR, et al. Food insufficiency is associated with high-risk sexual behavior among women in Botswana and Swaziland. PLoS Med. 2007;4(10):e260.CrossRefGoogle Scholar
  10. 10.
    World Health Organization: operations manual for delivery of HIV prevention, care and treatment at primary health centres in high-prevalence, resource-constrained settings, chapter 4: community. Accessed 31 Oct 2012.
  11. 11.
    The World Bank Group: operational challenges community home based care (CHBC) for PLWHA in Multi-Country HIV/AIDS Programs (MAP) for Sub-Saharan Africa. Africa region: working paper series no. 88. Accessed 31 Oct 2012.
  12. 12.
    Lehmann U, Sanders D. Community health workers: what do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. World Health Organization 2007. Accessed 8 Jan 2013.
  13. 13.
    Bajpai N. Dholakia RH. Improving the performance of accredited social health activists in India. Working paper series no. 1. Columbia Global Centers. Accessed 07 Nov 2011.
  14. 14.
    Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. Lancet. 2011;377:587–98.PubMedCrossRefGoogle Scholar
  15. 15.
    Wadler BM, Judge CM, Prout M, Allen JD, Geller AC. Improving breast cancer control via the use of community health workers in South Africa: a critical review. J Oncol. 2011;150423:1–8.CrossRefGoogle Scholar
  16. 16.
    Andersen MR, Yasui Y, Meischke H, Kuniyuki A, Etzioni R, Urban N. The effectiveness of mammography promotion by volunteers in rural communities. Am J Prev Med. 2000;18(3):199–207.PubMedCrossRefGoogle Scholar
  17. 17.
    Norris SL, Chowdhury FM, Van Le K, et al. Effectiveness of community health workers in the care of persons with diabetes. Diabet Med. 2006;23(5):544–56.PubMedCrossRefGoogle Scholar
  18. 18.
    Brownstein JN, Bone LR, Dennison CR, Hill MN, Kim MT, Levine DM. Community health workers as interventionists in the prevention and control of heart disease and stroke. Am J Prev Med. 2005;29(5 Suppl 1):128–33.PubMedCrossRefGoogle Scholar
  19. 19.
    Andrews JO, Felton G, Wewers ME, Heath J. Use of community health workers in research with ethnic minority women. J Nurs Scholarsh. 2004;36(4):358–65.PubMedCrossRefGoogle Scholar
  20. 20.
    Lewin SA, Dick J, Pond P, et al. Lay health workers in primary and community health care. Cochrane Database Syst Rev. 2005;(1):CD004015.Google Scholar
  21. 21.
    Rhodes SD, Foley KL, Zometa CS, Bloom FR. Lay health advisor interventions among Hispanics/Latinos: a qualitative systematic review. Am J Prev Med. 2007;33(5):418–27.PubMedCrossRefGoogle Scholar
  22. 22.
    Gogia S, Sachdev HS. Home visits by community health workers to prevent neonatal deaths in developing countries: a systematic review. Bull World Health Organ. 2010;88(9):658–66.PubMedCrossRefGoogle Scholar
  23. 23.
    Singh MK, Singh J, Ahmad N, Kumari R, Khanna A. Factors influencing utilization of ASHA services under NRHM in relation to maternal health in rural Lucknow. Indian J Commun Med. 2010;35(3):414–9.CrossRefGoogle Scholar
  24. 24.
    Srivastava DK, Prakash S, Adhish V, Nair KS, Gupta S, Nandan D. A study of interface of ASHA with the community and the service providers in Eastern Uttar Pradesh. Indian J Public Health. 2009;53(3):133–6.PubMedGoogle Scholar
  25. 25.
    Nyamathi A, Salem BE, Meyer V, Ganguly KK, Sinha S, Ramakrishnan P. Impact of an ASHA intervention on depressive symptoms among rural women living with AIDS in India: comparison of the ASHA Life and Usual Care program. AIDS Educ Prev. 2012;24(3):280–93.PubMedCrossRefGoogle Scholar
  26. 26.
    Nyamathi A, Ekstrand M, Zolt-Gilburne J, et al. Correlates of stigma among rural Indian women living with HIV/AIDS. AIDS Behav. 2011;17:329–39. doi: 10.1007/s10461-011-0041-9.CrossRefGoogle Scholar
  27. 27.
    Nyamathi A, Heravian A, Zolt-Gilburne J, et al. Correlates of depression among rural women living with AIDS in Southern India. Issues Ment Health Nurs. 2011;32(6):385–91.PubMedCrossRefGoogle Scholar
  28. 28.
    Rotheram-Borus MJ. Expanding the range of interventions to reduce HIV among adolescents. AIDS. 2000;14(Suppl 1):S33–40.PubMedCrossRefGoogle Scholar
  29. 29.
    Rotheram-Borus MJ, Stein JA, Lin YY. Impact of parent death and an intervention on the adjustment of adolescents whose parents have HIV/AIDS. J Consult Clin Psychol. 2001;69(5):763–73.PubMedCrossRefGoogle Scholar
  30. 30.
    Whitbeck LB, Hoyt DR, Bao WN. Depressive symptoms and co-occurring depressive symptoms, substance abuse, and conduct problems among runaway and homeless adolescents. Child Dev. 2000;71(3):721–32.PubMedCrossRefGoogle Scholar
  31. 31.
    Ekstrand ML, Chandy S, Gandhi M, Stewart W, Singh G. “Sometimes just run out”: delays in prescription refills as a risk for the development of HIV drug resistance in India. Toronto: XVI International Conference on AIDS; 2006. [Abstract TUPE0158].Google Scholar
  32. 32.
    Radloff L. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.CrossRefGoogle Scholar
  33. 33.
    Vijayaraghavan K. Control of micronutrient deficiencies in India: obstacles and strategies. Nutr Rev. 2002;60(5 Pt 2):S73–6.PubMedCrossRefGoogle Scholar
  34. 34.
    McDermott AY, Terrin N, Wanke C, Skinner S, Tchetgen E, Shevitz AH. CD4+ cell count, viral load, and highly active antiretroviral therapy use are independent predictors of body composition alterations in HIV-infected adults: a longitudinal study. Clin Infect Dis. 2005;41(11):1662–70.PubMedCrossRefGoogle Scholar
  35. 35.
    Oguntibeju OO, van den Heever WM, van Schalkwyk FE. The interrelationship between nutrition and the immune system in HIV infection: a review. Pak J Biol Sci. 2007;10(24):4327–38.PubMedCrossRefGoogle Scholar
  36. 36.
    Chang E, Sekhar R, Patel S, Balasubramanyam A. Dysregulated energy expenditure in HIV-infected patients: a mechanistic review. Clin Infect Dis. 2007;44:1509–17.PubMedCrossRefGoogle Scholar
  37. 37.
    AIDS Epidemic update. International consultation on the criminalization of HIV transmission. Geneva: Joint United Nations Programmes on HIV/AIDS and World Health Organization; 2009.Google Scholar
  38. 38.
    Koethe JR, Chi BH, Megazzini KM, Heimburger DC, Stringer JS. Macronutrient supplementation for malnourished HIV-infected adults: a review of the evidence in resource-adequate and resource-constrained settings. Clin Infect Dis. 2009;49(5):787–98.PubMedCrossRefGoogle Scholar
  39. 39.
    Liu E, Spiegelman D, Semu H, et al. Nutritional status and mortality among HIV-infected patients receiving antiretroviral therapy in Tanzania. J Infect Dis. 2011;204(2):282–90.PubMedCrossRefGoogle Scholar
  40. 40.
    Paton NI, Sangeetha S, Earnest A, Bellamy R. The impact of malnutrition on survival and the CD4 count response in HIV-infected patients starting antiretroviral therapy. HIV Med. 2006;7(5):323–30.PubMedCrossRefGoogle Scholar
  41. 41.
    Rabeneck L, Palmer A, Knowles JB, et al. A randomized controlled trial evaluating nutrition counseling with or without oral supplementation in malnourished HIV-infected patients. J Am Diet Assoc. 1998;98:434–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Berneis K, Battegay M, Bassetti S, et al. Nutritional supplements combined with dietary counselling diminish whole body protein catabolism in HIV-infected patients. Eur J Clin Investig. 2000;30(1):87–94.CrossRefGoogle Scholar
  43. 43.
    Saghayam S, Kumarasamy N, Cecelia AJ, Solomon S, Mayer K, Wanke C. Naïve population after 6 months of nevirapine-based generic highly active antiretroviral therapy in South India. Clin Infect Dis. 2007;44:295–300.PubMedCrossRefGoogle Scholar
  44. 44.
    Gershwin ME, Borchers AT, Keen CL. Phenotypic and functional considerations in the evaluation of immunity in nutritionally compromised hosts. J Infect Dis. 2000;182(Suppl 1):S108–14.PubMedCrossRefGoogle Scholar
  45. 45.
    Najera O, Gonzalez C, Cortes E, Toledo G, Ortiz R. Effector T lymphocytes in well-nourished and malnourished infected children. Clin Exp Immunol. 2007;148(3):501–6.PubMedCrossRefGoogle Scholar
  46. 46.
    Savino W, Dardenne M. Nutritional imbalances and infections affect the thymus: consequences on T-cell-mediated immune responses. Proc Nutr Soc. 2010;69(4):636–43.PubMedCrossRefGoogle Scholar
  47. 47.
    Chandra RK. Nutrition and immunology: from the clinic to cellular biology and back again. Proc Nutr Soc. 1999;58(3):681–3.PubMedCrossRefGoogle Scholar
  48. 48.
    Karsegard VL, Raguso CA, Genton L, Hirschel B, Pichard C. l-ornithine alpha-ketoglutarate in HIV infection: effects on muscle, gastrointestinal, and immune functions. Nutrition. 2004;20(6):515–20.PubMedCrossRefGoogle Scholar
  49. 49.
    Keithley JK, Swanson B, Zeller JM, et al. Comparison of standard and immune-enhancing oral formulas in asymptomatic HIV-infected persons: a multicenter randomized controlled clinical trial. JPEN (J Parenter Enter Nutr). 2002;26(1):6–14.CrossRefGoogle Scholar
  50. 50.
    Sattler FR, Rajicic N, Mulligan K, et al. Evaluation of high-protein supplementation in weight-stable HIV-positive subjects with a history of weight loss: a randomized, double-blind, multicenter trial. Am J Clin Nutr. 2008;88(5):1313–21.PubMedGoogle Scholar
  51. 51.
    Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive treatment to nutritional counseling in malnourished HIV-infected patients: randomized controlled trial. Clin Nutr. 1999;18(6):371–4.PubMedCrossRefGoogle Scholar
  52. 52.
    Shabert JK, Winslow C, Lacey JM, Wilmore DW. Glutamine-antioxidant supplementation increases body cell mass in AIDS patients with weight loss: a randomized, double-blind controlled trial. Nutrition. 1999;15(11–12):860–4.PubMedCrossRefGoogle Scholar
  53. 53.
    Swaminathan S, Padmapriyadarsini C, Yoojin L, et al. Nutritional supplementation in HIV-infected individuals in South India: a prospective interventional study. Clin Infect Dis. 2010;51(1):51–7.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Adeline Nyamathi
    • 1
    Email author
  • Sanjeev Sinha
    • 2
  • Kalyan K. Ganguly
    • 3
  • Padma Ramakrishna
    • 4
  • P. Suresh
    • 4
  • Catherine L. Carpenter
    • 1
    • 5
  1. 1.School of Nursing, University of California at Los AngelesLos AngelesUSA
  2. 2.All India Institute for Medical ResearchNew DelhiIndia
  3. 3.Indian Council for Medical ResearchNew DelhiIndia
  4. 4.NelloreIndia
  5. 5.Center for Human Nutrition, David Geffen School of Medicine at UCLALos AngelesUSA

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