Role of acquired immune deficiency syndrome-defining conditions in human immunodeficiency virus-associated wasting

Effect of BMI and fat mass on HIV disease progression in HIV-infected, antiretroviral treatment-naïve adults in Botswana

An obesity paradox has been proposed in many conditions including HIV. Studies conducted to investigate obesity and its effect on HIV disease progression have been inconclusive and are lacking for African settings. This study investigated the relationship between overweight/obesity (BMI≥25 kg/m2) and HIV disease progression in HIV+ asymptomatic adults not on antiretroviral treatment (ART) in Botswana over 18 months. A cohort study in asymptomatic, ART-naïve, HIV+ adults included 217 participants, 139 with BMI of 18·0-24·9 kg/m2 and seventy-eight participants with BMI≥25 kg/m2. The primary outcome was time to event (≥25 % decrease in cluster of differentiation 4 (CD4) cell count) during 18 months of follow-up; secondary outcomes were time to event of CD4 cell count<250 cells/µl and AIDS-defining conditions. Proportional survival hazard models were used to compare hazard ratios (HR) on time to events of HIV disease progression over 18 months. Higher baseline BMI was associated with significantly lower risk of an AIDS-defining condition during the follow-up (HR 0·218; 95 % CI 0·068, 0·701; P=0·011). Higher fat mass at baseline was also significantly associated with decreased risk of AIDS-defining conditions during the follow-up (HR 0·855; 95 % CI 0·741, 0·987; P=0·033) and the combined outcome of having CD4 cell count≤250/µl and AIDS-defining conditions, whichever occurred earlier (HR 0·918; 95 % CI 0·847, 0·994; P=0·036). All models were adjusted for covariates. Higher BMI and fat mass among the HIV-infected, ART-naïve participants were associated with slower disease progression. Mechanistic research is needed to evaluate the association between BMI, fat mass and HIV disease progression.

Vitamin D status and incidence of pulmonary tuberculosis, opportunistic infections, and wasting among HIV-infected Tanzanian adults initiating antiretroviral therapy

BACKGROUND

Maintaining vitamin D sufficiency may decrease the incidence of pulmonary tuberculosis and other infectious diseases. We present the first prospective study of vitamin D among human immunodeficiency virus (HIV)-infected adults receiving antiretrovirals in sub-Saharan Africa.

METHODS

Serum 25-hydroxyvitamin D (25(OH)D) level was assessed at antiretroviral therapy (ART) initiation for 1103 HIV-infected adults enrolled in a trial of multivitamins (not including vitamin D) in Tanzania. Participants were prospectively followed at monthly visits at which trained physicians performed a clinical examination and nurses took anthropometric measurements and assessed self-reported symptoms. Cox proportional hazards models estimated hazard ratios (HRs) of morbidity outcomes.

RESULTS

After multivariate adjustment, vitamin D deficiency (defined as a concentration of <20 ng/mL) had a significantly greater association with incident pulmonary tuberculosis, compared with vitamin D sufficiency (HR, 2.89; 95% confidence interval [CI], 1.31-7.41; P = .027), but no association was found for vitamin D insufficiency (defined as a concentration of 20-30 ng/mL; P = .687). Deficiency was also significantly associated with incident oral thrush (HR, 1.96; 95% CI, 1.01-3.81; P = .046), wasting (HR, 3.10; 95% CI, 1.33-7.24; P = .009), and >10% weight loss (HR, 2.10; 95% CI, 1.13-3.91; P = .019). Wasting results were robust to exclusion of individuals experiencing pulmonary tuberculosis. Vitamin D status was not associated with incident malaria, pneumonia, or anemia.

CONCLUSIONS

Vitamin D supplementation trials for adults receiving ART appear to be warranted.

Acceptability and effectiveness of chickpea sesame-based ready-to-use therapeutic food in malnourished HIV-positive adults

OBJECTIVE

A prospective descriptive study to assess acceptability and effectiveness of a locally made ready-to-use therapeutic food (RUTF) in HIV-infected chronically sick adults (CSA) with mid-upper-arm circumference (MUAC) <210 mm or pitting edema.

METHODS

Sixty-three wasted AIDS adults were prescribed 500 g representing ~2600 kcal/day of locally made RUTF for three months and routine cotrimoxazole. Weight, height, MUAC, Karnofsky score and morbidity were measured at admission and at monthly intervals. The amount of RUTF intake and acceptability were assessed monthly.

RESULTS

Ninety-five percent (60/63) of the CSA that were invited to join the study agreed to participate. Mean daily intake in these 60 patients was 300 g/person/day (~1590 Kcal and 40 g of protein). Overall, 73.3% (44/60) gained weight, BMI, and MUAC. The median weight, MUAC and BMI gains after three months were 3.0 kg, 25.4 mm, and 1.1 kg/m(2), respectively. The intervention improved the physical activity performance of participants and 78.3% (47/60) regained sufficient strength to walk to the nearest health facility. Mortality at three months was 18.3% (11/60).

CONCLUSION

Locally made RUTF was acceptable to patients and was associated with a rapid weight gain and physical activity performance. The intervention is likely to be more cost effective than nutritional support using usual food-aid commodities.

Psychiatric and neurophysiological predictors of obesity in HIV/AIDS

The objective of the study was to identify predictors of obesity. One hundred eleven nonobese and 48 obese HIV-1 seropositive patients provided information on medical history and other characteristics. They were then asked to detect the passage of 2-s time intervals while the contingent negative variation (CNV) was recorded. Obese patients were healthier, more likely to be receiving Highly Active Antiretroviral Therapy, and less likely to be substance dependent. Obese patients also exhibited a greater CNV slope and responded prematurely. A path model suggested that CD4+count and protease inhibitor use directly predicted obesity. Depression had no direct effect. However, when incorporated into a hypothetical construct, "mood dysregulation," that also included childhood conduct problems and stimulant dependence, the shared variance among the indicators did predict obesity. This relationship was mediated through premature response preparation (anterior scalp CNV amplitude) and its hypothesized association with impatience/impulsivity.

Obesity in HIV-infection: dietary correlates

OBJECTIVE

To describe the prevalence of obesity among a cohort of individuals living with HIV infection, and to determine differences in dietary intake among those subjects who are normal weight, overweight, and obese.

DESIGN

A cross-sectional study among participants enrolled in the Nutrition for Healthy Living (NFHL) study.

SETTING

Eligible participants included HIV-positive adults living in the greater Boston, MA and Providence, RI, areas. Subjects and Measures of Outcome: In total, 321 (265 males, 56 females) subjects were studied. Body composition measurements, demographic and health data, and fasting blood samples were analyzed. Dietary intake was assessed by three-day food records. Statistical analyses were performed using Statistical Package for Social Science (SPSS).

RESULTS

13% of males and 29% females were found to be obese. Energy intake per kilogram decreased by body mass index (BMI) category for both men and women (p <0.05). Although not different between groups, mean total fat and saturated fat intakes were above recommendations for both men and women in all BMI categories, while total grams dietary fiber decreased as BMI increased. Individuals in all BMI groups had micronutrient intakes below the Dietary Reference Intakes. Serum markers of insulin resistance were significantly different by BMI category among men and women, as well as triglycerides and total cholesterol for the males.

CONCLUSIONS

Obesity and diet in individuals living with HIV-infection needs to be addressed, as quality of dietary intake may have future implications regarding cardiovascular disease, metabolic syndrome, and other health risks associated with overweight and obesity.

Women's input into household decisions and their nutritional status in three resource-constrained settings

OBJECTIVE

To understand the role of women's input into household decisions as a possible factor contributing to women's undernutrition in settings where HIV/AIDS and drought have constrained household resources.

DESIGN AND SETTING

Three cross-sectional surveys of non-pregnant women in partnerships without a birth in the last 3 months were analysed. Factors associated with chronic energy deficiency (CED), defined as body mass index of<18.5 kg m(-2), were assessed among 1920 women in Zimbabwe, 2870 women in Zambia and 6219 women in Malawi.

RESULTS

Prevalence of CED was 4.2% in Zimbabwe, 13.5% in Zambia and 6.7% in Malawi. In Malawi, women with less input into decisions were more likely to have CED. After multivariable adjustment, each additional decision made by the partner increased the odds of CED in Malawi by 1.08 (95% confidence interval (CI) 1.02-1.15); each additional decision made by the woman decreased the odds of CED by 0.90 (95% CI 0.88-0.97). Malawian women with all the final say or with partners with no final say had significantly more CED than expected (odds ratio (OR)=2.88, 95% CI 1.42-5.83 and OR=1.64, 95% CI 1.06-2.52, respectively), and removing these points increased the magnitude and significance of the linear trends. In Zambia, the relationship was found for urban women only and no associations were found in Zimbabwe.

CONCLUSIONS

Input into household decisions may be a key factor in the cycle of drought and CED. Women with both low input and CED may lose productive capacity, putting them at greater risk of food insecurity and potentially HIV/AIDS in high prevalence settings.

ESPEN Guidelines on Enteral Nutrition: Wasting in HIV and other chronic infectious diseases

Undernutrition (wasting) is still frequent in patients infected with the human immunodeficiency virus (HIV), despite recent decreases in the prevalence of undernutrition in western countries (as opposed to developing countries) due to the use of highly active antiretroviral treatment. Undernutrition has been shown to have a negative prognostic effect independently of immunodeficiency and viral load. These guidelines are intended to give evidence-based recommendations for the use of enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) in HIV-infected patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. Nutritional therapy is indicated when significant weight loss (>5% in 3 months) or a significant loss of body cell mass (>5% in 3 months) has occurred, and should be considered when the body mass index (BMI) is <18.5 kg/m(2). If normal food intake including nutritional counselling and optimal use of ONS cannot achieve an adequate nutrient intake, TF with standard formulae is indicated. Due to conflicting results from studies investigating the impact of immune-modulating formulae, these are not generally recommended. The results obtained in HIV patients may be extrapolated to other chronic infectious diseases, in the absence of available data.

Nutrition and HIV infection: review of weight loss and wasting in the era of highly active antiretroviral therapy from the nutrition for healthy living cohort

Despite major advances in the treatment and survival of patients infected with human immunodeficiency virus (HIV), weight loss and wasting remain common problems. In the HIV-infected population, weight loss is associated with lower CD4+ cell counts and is an independent predictor of mortality. The etiology of weight loss and wasting is complex and multifactorial. We discuss, on the basis of a large longitudinal cohort that examined nutritional status in HIV infection, data on weight loss and wasting from the present clinical era. The definition, prevalence, and significance of HIV-associated weight loss and wasting are summarized. The etiology of weight loss is discussed for 2 main categories: inadequate nutrient intake and altered metabolism. Finally, studies of interventions to treat HIV-associated weight loss and wasting are discussed. This information is intended to raise awareness among health care providers of HIV-infected patients that weight loss and wasting remain important acquired immunodeficiency syndrome-defining conditions, despite the advent of HAART.

HIV-Related Wasting in HIV-Infected Drug Users in the Era of Highly Active Antiretroviral Therapy

BACKGROUND

A decrease in the rate of human immunodeficiency virus (HIV) infection-related wasting has been reported in the era of highly active antiretroviral therapy (HAART). We investigated this concern in a hard-to-reach population of HIV-infected drug users in Miami, Florida.

METHODS

After informed consent was obtained, 119 HIV-infected drug users were administered questionnaires involving demographic, medical history, and food-security information. Blood samples were drawn for immunological and viral studies. HIV-related wasting over a period of > or =6 months was defined as a body mass index of <18.5 kg/m2, unintentional weight loss of > or =10% over 6 months, or a weight of <90% of the ideal body weight.

RESULTS

The prevalence of HIV-related wasting was 17.6%. A significantly higher proportion of those who experienced wasting (81%) reported that there were periods during the previous month when they went for > or =1 day without eating (i.e., food insecurity), compared with those who did not experience wasting (57%). Although a greater percentage of patients who experienced wasting were receiving HAART, their HIV RNA levels were more than twice as high (mean+/-standard deviation [SD], 166,689+/-238,002 copies/mL; median log HIV RNA level +/- SD, 10.2+/-2.7 log10 copies/mL) as those for the group that did not experience wasting (mean+/-SD, 72,156 +/- 149,080; median log HIV RNA level+/-SD, 9.2+/-2.3 log10 copies/mL). Participants who experienced wasting were more likely to be heavy alcohol drinkers and users of cocaine. In multivariate analysis that included age, sex, food security, alcohol use, cocaine use, viral load, and receipt of antiretroviral therapy, the only significant predictors of wasting were > or =1 day without eating during the previous month (odds ratio [OR], 1.96; 95% confidence interval [CI], 1.18-3.26; P=.01) and viral load (OR, 1.64; 95% CI, 1.00-2.69; P=.05).

CONCLUSIONS

HIV-related wasting continues to be common among HIV-infected drug users, even among HAART recipients. Food insecurity and viral load were the only independent predictors of wasting. The social and economic conditions affecting the lifestyle of HIV-infected drug users constitute a challenge for prevention and treatment of wasting.

Wasting during pregnancy increases the risk of mother-to-child HIV-1 transmission

OBJECTIVES

To examine whether wasting during pregnancy, as measured by weight loss and low weight gain, is associated with increased mother-to-child transmission (MTCT) of HIV-1.

METHODS

This was a cohort study in Dar es Salaam, Tanzania, among 957 HIV-1-infected pregnant women. Weight was measured at the first prenatal visit and every month thereafter until delivery. Weight loss was defined as a weekly rate of weight gain </=0 and low weight gain as a weekly rate >0 and </=166 g/wk. The incidences of presumptive intrauterine transmission (HIV status at birth) and presumptive intrapartum and early breast-feeding transmission (HIV status at 6 weeks) were examined in relation to baseline anthropometric characteristics and weight change during pregnancy using 2xn tables and multivariable binomial regression.

RESULTS

Compared with women who gained >/=167 g/wk, weight loss during pregnancy was related to higher risk of intrauterine MTCT (adjusted relative risk [RR] = 2.32, 95% CI = 1.23-4.36, P = 0.009), HIV positive at birth or fetal death (RR = 2.13, 95% CI = 1.40-3.24, P = 0.0004), and HIV positive at birth or early neonatal death (RR = 1.96, 95% CI = 1.26-3.07, P = 0.003). The rate of weight gain during the 3rd trimester was inversely related to the risk of intrapartum/early breast-feeding transmission (adjusted P value, test for trend = 0.05).

CONCLUSIONS

Weight loss during pregnancy increases the risk of early MTCT. Identifying causes of wasting during pregnancy may provide clues for new strategies to prevent MTCT.

Food insecurity and hunger are prevalent among HIV-positive individuals in British Columbia, Canada

Hunger and food insecurity are important factors that may affect an individual's nutritional state and should therefore be assessed in nutrition surveillance activities. The objective of this study was to determine the level of food insecurity and hunger among HIV-positive persons accessing antiretroviral therapy in British Columbia. A cross-sectional study was performed in the BC HIV/AIDS drug treatment program, a province-wide source of free-of-charge antiretroviral medications. In 1998-1999, participants completed a questionnaire focusing on personal information, health, and clinical status. Food and hunger issues were evaluated with the Radimer/Cornell questionnaire. Overall, 1213 responding men and women were classified as food secure (52%), food insecure without hunger (27%), or food insecure with hunger (21%). In both categories of food insecurity, individuals were significantly more likely to be women, aboriginals, living with children, and to have less education, a history of recreational injection drug and/or alcohol abuse, and an unstable housing situation (P < 0.05). In logistic multivariate modeling, income < or = Can$10,000 [adjusted odds ratio (AOR) 3.78, 95% CI (2.53-5.65)], shared household with children [AOR 3.68, 95% CI (1.98-6.84)] and unemployment [AOR 3.15, 95% CI (1.94-5.13)] were the strongest predictors of hunger. In HIV-positive individuals, the occurrence of food insecurity was nearly 5 times higher than in the general Canadian population. The results should stimulate further research to identify to what extent hunger-associated factors are reversible with interventions built on nutritional and/or social strategies.

Understanding the Role of HIV Load in Determining Weight Change in the Era of Highly Active Antiretroviral Therapy

BACKGROUND

In this prospective cohort study, we determined the relationship between human immunodeficiency virus (HIV) RNA load and body weight in patients with HIV infection.

METHODS

Repeated-measures analysis was restricted to patients with >or=2 study visits, 4-9-month intervals between study visits, and complete data on virus load, resting energy expenditure (REE), and highly active antiretroviral therapy (HAART). The outcome was change in body weight across study intervals. The main predictor was virus load. Separate analyses were performed for weight change in patients receiving and patients not receiving HAART.

RESULTS

The eligible sample consisted of 318 participants associated with 1886 study intervals. Sixty-one patients (19%) were women, and 173 (54%) were undergoing HAART at the time of enrollment. There was a significant interaction (P=.01) between virus load and HAART use. In the absence of HAART, each log(10) increase in virus load was associated with a 0.92-kg decrease in body weight (P=.003), but during HAART, virus load was not significantly associated with weight change. During HAART, a CD4(+) cell count decrease of 100 cells/mm(3), rather than a change in the virus load, was associated with a 0.35-kg decrease in body weight (P<.001). REE was independently associated with weight change in both models (P<.001).

CONCLUSIONS

Patients with HIV infection who are losing weight and are not taking HAART should be considered for HAART. Patients who are already receiving HAART and have unsuppressed virus loads may benefit virologically from an intensified regimen, because such a regimen may lead to complete suppression if there is an accompanying increase in CD4(+) cell counts. Further research is needed to understand the strong independent effect of changes in REE among patients receiving and patients not receiving HAART.

Weight loss during pregnancy is associated with adverse pregnancy outcomes among HIV-1 infected women

In a prospective study of 1002 pregnant, HIV-1 infected Tanzanian women, we examined the incidence of fetal death, preterm delivery, low birth weight (LBW), and small for gestational age (SGA) births in relation to maternal anthropometry at the first prenatal visit, weight loss, and low weight gain during pregnancy. Anthropometric measurements were obtained monthly during the 2nd and 3rd trimesters. Low maternal height and weight at the first visit were significantly related to lower mean birth weight and increased risk of SGA, but not to preterm delivery. Maternal stature < 150 cm was significantly related to fetal death. Weight loss during pregnancy, defined as a negative slope of the regression of weight measurements on the week of gestation, occurred in 10% of the women. It was related to increased relative risk (RR) of fetal death (RR = 1.83, 95% CI = 0.93, 3.57), preterm delivery (RR = 1.85, 95% CI = 1.40, 2.44), and LBW (RR = 2.85, 95% CI = 1.69, 4.79) after adjusting for multivitamin supplementation, height, primiparity, baseline weight, malaria, CD4 cell count, HIV disease stage, and intestinal parasitoses. The significant association with fetal death was stronger for weight loss during the 2nd trimester, whereas increased risks of preterm delivery and LBW were higher for weight loss during the 3rd. Similar but weaker associations were found with low weight gain during pregnancy (slope < 25th percentile). We conclude that poor anthropometric status at the first prenatal visit and weight loss during pregnancy among HIV-1 infected women are strong risk factors for adverse pregnancy outcomes.