Malnutrition (HIV/AIDS) — August’s Story
Introduction
The patient interaction protocol mandates strict adherence to hand hygiene before patient contact. Before engaging with patients, the dietitian emphasizes hand hygiene and evaluates the need for additional personal protective equipment (PPE). Refer to the the WHO hand-washing technique here.
Next the dietitian introduces themselves and verifies the patient's identity using two forms of identification: the patient's chart and verbal confirmation. Consider cultural sensitivity and the patient's emotional well-being. Please take a moment now to practice your patient introduction technique. Practice introducing yourself and explaining the purpose of your visit to August. Watch the Dietitian's Introduction with Patient here.
Background
August is a 48-year-old Zulu-speaking man who lives with his wife and two sons in an informal settlement 5 km from the Dr. George Mukhari Hospital, close to Sefako Makgatho Health Sciences University Hospital (SMHSU) where you work as a clinical dietitian. August was diagnosed with human immunodeficiency virus (HIV) at the age of 28 (horizontal transmission) and is currently on fixed-dose combination regimen of tenofovir, lamivudine and dolutegravir. He reports to be compliant with treatment. He is admitted SMHSU hospital with a clinical picture of parapneumonic effusion with a possible etiology of streptococcus pneumonia. This is his first consultation with a dietitian. He has received no dietary advice in the past.
Click here for the patient's self-assesment questionnaire.
August presented to emergency 3 days ago with fever, shortness of breath, and severe left upper-quadrant pain. His chart notes mucositis with oral candidiasis and mouth ulcers, dysgeusia, and a lack of appetite. He reports a persistent cough, weakness, and a general malaise over the past 3 weeks, with disinterest in usual activities and spending most of the day resting in bed. On admission, oral pain and altered taste made eating and drinking uncomfortable; however, over the last 48–72 hours his appetite, intake, and oral pain have begun to improve. He remains tired but is now more willing to sit up in a chair and engage with the care team.
Click here for August's 24-hour Hospital Intake
August is unemployed and receives a disability grant of R2090 ($170 AUD) per month, from the South African Social Security Agency (SASSA). August’s wife is employed as a cleaner at the local school and earns a monthly salary of R6000 ($500 AUD). August’s children contribute R7500 ($600 AUD) to the household monthly income. Together, this income covers the living expenses of four people. Typically, 60% of this sum is spent on food, while the remainder goes towards transportation and household expenses.
Food and Nutrition-Related History (FH)
Diet history, intake patterns, access, culture, preferences, symptoms.
The dietary history is a retrospective, structured interview designed to assess habitual intake from the core food groups. It also explores dietary behaviours, including meal patterns, cultural practices, and nutrition impact factors. This method is particularly useful for identifying usual intake and long-term dietary habits over a defined period. In August’s case, the dietitian considers his usual intake over the preceding six months, corresponding with the onset of weight loss. Evaluating dietary patterns during this period enables identification of nutrient deficiencies or imbalances contributing to malnutrition, thereby informing a comprehensive nutrition assessment and the development of a targeted intervention plan. Use the information in the videos below with August's Diet History to gather information for the Activity 18.1 Completing Nutrition Analysis.THe dietitian also considers August's dietary intake during the hospital admission. See August's Medical Chart.
Activity — Protein Sources & Frequency
List usual animal/plant proteins and weekly frequency. Note barriers (cost, dislike, texture, symptoms). Consider low-cost exchanges.
Consider beans/legumes, eggs, amasi; check local prices.
Activity — Protein-Energy Risk
Estimate protein adequacy vs needs. Consider budget-friendly meals that hit protein targets.
Use legumes + cereals; add dairy/egg where feasible.
Activity — Food Budget Map
Consider the factors impacting August's food security. Begin to think about ways of improving access to nutrient-dense foods.
Work within stated monthly food spend.
Activity — % Budget on Food
Review the diet history. Calculate food % of income and list two high-impact changes to meet nutrition needs.
Activity — Food Security Screener
Create 2–3 food access questions to revisit at each check-in and note referral options.
Activity — Basket Rebuild
Reallocate spend to preserve protein/energy density without increasing cost.
Activity — Contingency Plan
Outline backup options (community kitchens, food parcels, faith groups) with contact points.
Anthropometry
Activity — Sources & Accuracy
List where you’ll obtain measurements; annotate dates/methods and reliability (edema, dehydration, scale type).
Activity — Trajectory
Plot weights and % loss over 1, 3, 6 months with available data. Mark thresholds that trigger diagnosis/escalation.
Consider MUAC if <22 cm; verify scale consistency.
Activity — Risk Synthesis
Link disease burden to likely lean mass loss; document verification measures (repeat weight, MUAC, handgrip if available).
Medications, Tests & Procedures
Activity — Dose Timing & Meals
THink about dose timing vs meals; note side-effects affecting intake; add one adherence support (reminder, blister pack, synced refills).
Activity — Access & Follow-up
Map the testing/clinic pathway; list access issues that could interrupt continuity (transport, fees, hours).
Activity — Procedure Implications
Think about peri-procedure nutrition (fasting, re-feeding timing, analgesia/antiemetic coordination) and fluid needs.
Nutrition-Focused Physical Findings (NFPF) & Symptoms
Activity — Oral Pain → Intake
List two texture/temperature changes and one mouth-care step to improve intake when it was poor.
Think about how you would coordinate with clinical team - antifungals/analgesia.
Activity — Symptom Map
Connect appetite/oral pain to intake barriers. Consider two practical eating strategies for today and one to trial at home.
Activity — Pre-admission Impact
Describe how symptoms likely reduced intake and which red flags require urgent escalation.
Activity — 48–72h Plan
Prioritize two actions for the next 48–72h that would most improve intake given current symptoms.
Client History
Activity — Social Support Map
Identify caregiver roles and one community referral that could reduce burden or improve access.
Activity — Access & Transport
Note clinic distance/transport costs and propose one tele-check or visit consolidation tactic.
Activity — Constraints Log
List the two biggest non-food constraints impacting nutrition care (time, travel, stigma, admin).
Activity — Eligibility & Paperwork
List alternative programs/appeals and documents needed to qualify for added support.
Activity — Privacy & Safety
Note any privacy/safety concerns that change where/how advice is delivered; write one trauma-informed phrase.
Activity — Language & Framing
Draft one patient-preferred phrase that reduces stigma during counseling or handover.
Activity — Synthesize to PES
Review the diet history and consider the information you have gathered from the videos. Begin to think about a diagnosis.
Activity — ONS Alternatives
List two food-based alternatives if commercial ONS aren’t accessible; include portion and timing.
Activity — Tolerance Check
Record tolerance (volume, symptoms, flavor). Note changes that could improve acceptance.