The nutritionist investigating the effect of HIV treatments on mothers and babies

When Florence Nabwire didn’t get funding for medical school, she decided to train as a nutritionist. She excelled and went on to set up a pioneering nutrition education scheme at 72 health centres in rural Uganda. Her research as a PhD student focuses on nutrition and HIV — especially in mothers and babies.

Florence Nabwire and daughter (Nick Saffell)

I first saw a baby with HIV in 2010. I was doing a master’s course in nutrition at the University of Nairobi and I’d travelled to Kampala in Uganda to work as a volunteer nutritionist at Baylor College of Medicine, a clinic that provides care and support for more than 6,000 HIV-infected children and their families. I later became a nutrition officer.

It was a huge shock to see babies who were just skin and bones, but fulfilling to see them transformed after three to six months of nutrition rehabilitation. The HIV virus takes a huge toll on the body’s energy requirements which is why weight loss is a key feature of the AIDS stage. HIV-infected children, like adults, will need to take antiretroviral drugs (ARVs) for the rest of their lives to reduce multiplication of the virus and progression to AIDS.

The poorest women seeking treatment at the clinics sometimes walk for hours to get there — and then hours to get home. They don’t have the small amount of money needed for the bus fare. Poverty is just one of their problems — there’s also the stigma of having HIV.

Florence conducts a nutrition session at the Baylor Center in Kampala

The Baylor clinic in Kampala is a state-of-the-art facility and the national referral centre for HIV-infected children. Out in the rural areas, facilities are much more basic. There was a big burden of malnutrition and food insecurity among patients. Some patients reported side effects after taking ARVs on an empty stomach. With my background in nutrition, I spotted a need to integrate food and nutrition services into HIV programmes.

Good nutrition delays progression of HIV to AIDS and plays a vital role in a good clinical outcome. A well-nourished person has a strong immunity to fight off opportunistic infections like TB and will respond better to ARVs. But patients need to know how to combine the foods available to them to achieve a balanced diet and meet their energy demands. Nutrition counselling needs to be part of the treatment package.

From 72 clinics supported by Baylor in rural Uganda, I integrated nutrition into HIV care. I rolled out a nutrition programme to identify and rehabilitate malnourished babies and adults, and educate on breastfeeding. We set up practical sessions on preparing nutritionally balanced meals for both adults and babies to prevent malnutrition. The programme also provided food, agricultural inputs and trained households on improved farm practices.

Florence leads a field demonstration to improve agricultural practices

I never for a moment imagined I’d do a PhD at Cambridge. I was brought up in Mombasa, the third child of six. My parents were both teachers but their wages weren’t enough to pay the fees at private schools so I went to a government school where standards of achievement were low.

My father gave me extra tuition after school. I did well enough to get into a girls’ secondary school that suited me perfectly. I did lots of sport including heptathlon, hockey and netball up to national level. My father was worried that I was neglecting my studies but I also did well academically.

Coast Girls High School Hockey Team, Mombasa 1999 (Florence standing extreme right)

Growing up, I always wanted to be a medical doctor. Although I got the grades needed, I wasn’t offered government funding that would enable me to train. Instead I took a degree in food science and technology in the Faculty of Agriculture at the University of Nairobi. I graduated as top student in the faculty and was offered a scholarship to take a master’s in applied human nutrition.

Florence examines a sweet potato crop in a demonstration garden, Eastern Uganda.

Cambridge University came on to my horizon when I began researching graduate courses. I used to receive an undergraduate prospectus after I completed secondary school and the historic colleges seemed like a dream world. In 2012 I saw an advert for Gates Cambridge Scholarships and decided to apply.

I sent an introductory email to MRC Human Nutrition Research in search of a PhD supervisor. An interview on Skype was followed by many months of emails, calls and draft proposals before a PhD project was agreed.

Applying for Gates and Cambridge international scholarships was a big gamble. For Gates, each year there are more than 4,500 applicants from around the world for just 50 scholarships. I didn’t think I had a chance. But I was awarded both scholarships. I accepted a Gates scholarship and became a member of a fantastic international community.

Seven months ago, I had my second baby. I introduced her to solid foods at six months. Until then she was exclusively breastfed and I received support from the midwives. People assume that breastfeeding comes automatically — but women need a lot of support, especially in the first few weeks.

Previously, women who were HIV positive were advised not to breastfeed. The virus can be passed to their babies via breast milk. They had to use formula or cow’s milk which are expensive and not as nutritionally beneficial as breastmilk. As a result, many babies born to HIV-infected mothers were dying of malnutrition.

Today, even in resource-poor settings, HIV-infected women are able to breastfeed safely. But only if they maintain good adherence to their ARVs.

My PhD project compares bone health in HIV-positive and HIV-negative mothers and their babies. I studied 100 women who are HIV positive and 100 HIV negative, following them through pregnancy and into the first three months of their babies’ lives.

It proved difficult to recruit HIV positive women for the study. It took a full year of hard work. There was a lot of vital paper work to complete. So, the fieldwork lasted three years and overran into my third year of PhD.

The study provides data on calcium requirements for HIV-infected mothers and their babies. Pregnancy and lactation are associated with physiological changes in bone mineral, but most evidence shows that this is recovered after weaning. Initiation of ARVs is independently associated with a decrease in bone mineral within the first two years, but data are limited in pregnant and breastfeeding women.

My hypothesis is that ARVs may disrupt the normal process of calcium mobilisation from the mothers’ skeleton. I’m finding our whether this leads to bone loss that is not recovered or to compromised growth and bone mineral deposition in their babies.

I’ve almost finished writing up my dissertation. I’m excited about the results and I plan to continue a career in research. Just where I’ll be based, I don’t yet know. Having dreamed of being a medical doctor, I’m grateful that I went down a different line. My research has potential to inform clinical care for HIV-infected mothers and their babies.

This profile is part of our This Cambridge Life series.

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