ABSTRACT
Human immuno-deficiency virus (HIV) remains a significant cause of morbidity and mortality worldwide, particularly in Sub-Saharan Africa. Many countries with a high HIV burden are also food insecure, which increases the risk of undernutrition by causing multiple micronutrient deficiencies. This can hinder immune function and further HIV disease progression. The definition of palliative care has been refocused to suggest that care can be provided as early as possible along the course of a chronic illness as opposed to being reserved for the final stages. This includes HIV, as individuals will require care throughout the course of the infection. With the rollout of antiretroviral therapy, individuals with HIV are living longer and are experiencing higher levels of morbidity compared to their HIV-negative counterparts. Therefore, the need for palliative care has dramatically increased despite the lack of access in low-income countries. Ready-to-use therapeutic foods were initially developed to treat severe acute malnutrition in children but are also used as a food supplement for people living with HIV. Irrespective of HIV status, the World Health Organization recommends therapeutic food supplementation for severely undernourished individuals (body mass index [BMI] less than 16 kg/m2) until their BMI becomes stabilized. Several studies conducted in countries with a triple burden of HIV, food insecurity and undernutrition have shown the effectiveness of ready-to-eat therapeutic foods in (1) reversing micronutrient deficiencies, (2) causing weight gain and (3) improving antiretroviral therapy adherence. Using a randomized-controlled trial to assess the efficacy of a food supplement in a food-insecure population can pose an ethical dilemma. If all participants are HIV positive and uniformly food insecure, it may be unethical to administer a food supplement to one group and not the other. In infants, exclusive breastfeeding is largely superior to replacement feeding, even in the presence of HIV. Even with a highly nutritional formula, administering can be problematic due to high cost, lack of clean water for mixing or stigma attached to women who do not breastfeed. Despite its effectiveness, food supplementation is not a sustainable initiative in isolation. It is necessary to approach food supplementation as part of a long-term food security intervention, such as the investment in 100% locally produced therapeutic foods.
