“When you get right down to it, food is practically the whole story every time.”

-- Kurt Vonnegut, Galápagos

The nutritional health of people with HIV is still very much an afterthought in AIDS care and research. Consider this: Last year’s ACT UP/Philadelphia AIDS Standard of Care, published in POZ No. 7, recommends nutrition intervention only for PWAs with CD4 counts under 500. The suggested action? “Treat nutritional deficiencies, get dietary counseling and take vitamins.” Sound advice, but it overlooks nutrition’s greatest strength -- its preventive capabilities. The best time to counter nutritional deficiencies is before they lead to wasting, and the best way to do it is with food.

Perhaps good nutrition sounds like a platform for a nagging mother, so people may dismiss dietary issues as less important than others in HIV treatment. Indeed, enhancing PWAs’ access to food, nutrients and supplements was not among the items on the AIDS community coalition agenda of 50 actions proposed to President Clinton at the White House Conference on AIDS in December (see POZ No. 12).

The problem is more the frame than the picture: HIV-associated malnutrition is often approached primarily in biomedical terms, as an individual problem that warrants clinical solutions only after nutritional depletion has occurred. In this view, “nutrition” for PWAs often amounts to costly, high-tech supplements and formulas consumed orally, through a tube or intravenously to correct malnutrition. This approach is reinforced by the use of appetite stimulants, anabolic agents and anti-inflammatory drugs. In many cases, this complicated and expensive regime could have been avoided or at least lessened by proper attention to nutrition in earlier stages of HIV infection.

On the other hand, some people collapse nutrition (of the more low-tech variety) into the category of “alternative treatments,” which sometimes promotes an either/or approach: You use either Western or non-Western therapies, but not both. A common variant of this approach focuses on isolated nutrients while overlooking the power of both food and medications. But nutrition shouldn’t be reduced to supplements or thought of as an alternative therapy, rather as an essential cotherapy that complements medical management of HIV infection.

Undeniably, nutrients and supplements have a key role to play in HIV nutrition, but surely the place to begin is with an eating plan offering a broad variety of freshly and safely prepared food. PWAs who have tried to take antiretrovirals along with prophylactics and symptom-relief meds will adamantly testify that if they don’t eat good food or get some form of nutrition support, even for a few days, they will experience major medication intolerance secondary to malnutrition.

A fundamental change must occur in how we think about nutrition and HIV. This means fostering a dialogue among those with various nutrition perspectives, integrating the most desirable features into a more comprehensive vision of medical care and carefully constructing a nutrition research agenda linked to effective policy outcomes. One of the most important outcomes is to have the entire AIDS community link nutrition interventions to all of its other initiatives. Nutrition must be built into agendas for AIDS conferences, research and policy, but this can only happen if it is embedded in the thoughts, vocabulary and actions of people who fund, design and deliver AIDS programs.

Specifically, what does this mean? Health care providers discussing nutrition when prescribing drugs; accessible nutrition counseling and education for PWAs and their caregivers; more funding for group and home-delivered meal programs; public and private insurance coverage of nutritional supplements and counseling; drug company support for HIV nutrition research; and awareness by policymakers of the link between nutrition, cost-effective health care and enhanced quality of life.

A comprehensive nutrition research agenda can provide the data required to shed light on the prevalence, severity and progression of HIV-associated malnutrition and the mechanisms of the wasting syndrome. We need high-quality, community-based research to find out what types of interventions work best, with which groups, under what circumstances, and why.

Finally, strong leadership is an essential ingredient in the recipe for increased awareness of nutrition’s role in managing HIV. That means nutritionists, doctors and other care providers should join advocates in developing an agenda and offering ongoing information to policymakers. The AIDS community must become as aggressively vocal in urging viable solutions to the HIV nutrition problem as it is in demanding expanded access to clinical trials and faster FDA approval of drugs to fight HIV infection.