Lifestyle Interventions

Based on recommendations by the US Preventative Services Task Force

Dietary counselling

  • Dietary intervention should not interfere with the dietary requirements necessary for appropriate absorption of ART drugs (e.g. maintaining sufficient calorie intake for RPV).
  • Keep caloric intake balanced with energy expenditure
  • Limit intake of saturated fat, cholesterol and refined carbohydrates
  • Reduce total fat intake to < 30% and dietary cholesterol to < 300 mg/day
  • Emphasise intake of vegetables, fruit and grain products with fibre
  • Cut back on beverages and foods with added sugar
  • Choose and prepare foods with little or no salt. Adequate intakes of sodium in adults have been estimated mostly around 1.5 g/day (corresponding to 3.8 g salt/ day [1]
  • Emphasise consumption of fish, poultry (without skin) and lean meat
  • Consider referral to dietician, one-week food and drink diary to discover ‘hidden’ calories
  • Avoid binge eating (‘yo-yo dieting’)
  • In persons with HIV-related wasting and dyslipidaemia, address wasting first and consider referral to dietician
  • Persons who are obviously overweight should be motivated to lose weight. Starvation diets are not recommended (immune defence mechanisms potentially decreased). Malnutrition has to be addressed where observed.
    Normal BMI range: 18.5-24.9;
    Overweight: 25.0-29.9,
    Obesity: > 30.0 kg/m2
  • The following questions are helpful to determine average alcohol intake
    1. How often do you drink alcohol:
      never, ≤ 1/month, 2-4x/month, 2-3x/week, > 4x/week
    2. If you drink alcohol, how much typically at a time:
      1-2, 3-4, 5-6, 7-9, > 10 drinks
    3. How many times do you have 6 or more alcoholic drinks at one occasion:
      never, < 1/month, 1x/month, 1x/week, more or less daily
  • Intake of alcohol should be restricted to no more than one drink per day for women and two drinks per day for men (< 20-40 g/day)
  • In particular, persons with hepatic disease, see NAFLD, adherence problems, inadequate CD4 count increase, tumours, past tuberculosis, diarrhoea and other conditions associated with high alcohol intake should be motivated to decrease or stop alcohol intake

Exercise promotion

  • Promote active lifestyle to prevent and treat obesity, hypertension and diabetes
  • Encourage self-directed moderate level physical activity (take the stairs, cycle or walk to work, cycling, swimming, hiking, etc.)
  • Emphasise regular moderate-intensity exercise rather than vigorous exercise
  • Achieve cardiovascular fitness (e.g. 30 minutes brisk walking > 5 days a week)
  • Maintain muscular strength and joint flexibility

Smoking cessation

  • HIV-positive tobacco users should be made aware of the substantial health benefits of smoking cessation which include reducing the risk of tobacco-related diseases, slowing the progression of existing tobacco related disease, and improving life expectancy by an average of 10 years.
  • Regularly consider the following algorithm with two major questions:

Adapted from [2] and [3]

  1. Pharmacotherapy: Nicotine replacement therapy: nicotine substitution (patch, chewing gum, spray), varenicline and bupropion are approved by the EMA. Bupropion is contraindicated with epilepsy and varenicline may induce depression. Bupropion may interact with PIs and NNRTIs, see Drug-drug Interactions between ARVs and Non-ARVs
  2. Cognitive-behavioral counselling: Use specific available resources. Either individual or group interventions to better suit and satisfy the PLWH. The programme should consist of four or more sessions lasting 30 minutes for 3-4 months
  3. Motivational strategy: Identify potential health risks of the smoker and to stratify both acute (e.g. exacerbations of COPD) and long-term (e.g. infertility, cancer) risks. Show the PLWH the personal benefits of stopping smoking. Identify the barriers or obstacles that might impede the success of a quit attempt. Smoking cessation interventions should be delivered repeatedly, as long as the PLWH is not willing/ready enough to quit smoking


At this moment, neither EMA nor FDA approve e-cigarettes as a smoking cessation agent. In PLWH there is no data on long term outcomes and it is not possible to add any more specific recommendations. EACS follows the statement issued by the CDC in 2018 [4]

  • E-cigarettes have the potential to benefit adult smokers who are not pregnant if used as a complete substitute for regular cigarettes and other smoked tobacco products
  • E-cigarettes are not safe for people who do not currently use tobacco products
  • E-cigarettes have the potential to benefit some people and harm others, however, whether e-cigarettes are effective for quitting smoking has not been definitively established
  • E-cigarettes should not be recommended in persons who never smoked or used other tobacco products or e-cigarettes.
  • E-cigarettes may have a potential benefit if used as a complete substitution for tobacco, but are not considered safe if not currently using tobacco products