Levels of HIV RNA are quantitatively related to prior weight loss in HIV-associated wasting

Adipose Tissue Dysfunction and Energy Balance Paradigms in People Living With HIV

Over the past 4 decades, the clinical care of people living with HIV (PLWH) evolved from treatment of acute opportunistic infections to the management of chronic, noncommunicable comorbidities. Concurrently, our understanding of adipose tissue function matured to acknowledge its important endocrine contributions to energy balance. PLWH experience changes in the mass and composition of adipose tissue depots before and after initiating antiretroviral therapy, including regional loss (lipoatrophy), gain (lipohypertrophy), or mixed lipodystrophy. These conditions may coexist with generalized obesity in PLWH and reflect disturbances of energy balance regulation caused by HIV persistence and antiretroviral therapy drugs. Adipocyte hypertrophy characterizes visceral and subcutaneous adipose tissue depot expansion, as well as ectopic lipid deposition that occurs diffusely in the liver, skeletal muscle, and heart. PLWH with excess visceral adipose tissue exhibit adipokine dysregulation coupled with increased insulin resistance, heightening their risk for cardiovascular disease above that of the HIV-negative population. However, conventional therapies are ineffective for the management of cardiometabolic risk in this patient population. Although the knowledge of complex cardiometabolic comorbidities in PLWH continues to expand, significant knowledge gaps remain. Ongoing studies aimed at understanding interorgan communication and energy balance provide insights into metabolic observations in PLWH and reveal potential therapeutic targets. Our review focuses on current knowledge and recent advances in HIV-associated adipose tissue dysfunction, highlights emerging adipokine paradigms, and describes critical mechanistic and clinical insights.

HIV and antiretroviral therapy-related fat alterations

Early in the HIV epidemic, lipodystrophy, characterized by subcutaneous fat loss (lipoatrophy), with or without central fat accumulation (lipohypertrophy), was recognized as a frequent condition among people living with HIV (PLWH) receiving combination antiretroviral therapy. The subsequent identification of thymidine analogue nucleoside reverse transcriptase inhibitors as the cause of lipoatrophy led to the development of newer antiretroviral agents; however, studies have demonstrated continued abnormalities in fat and/or lipid storage in PLWH treated with newer drugs (including integrase inhibitor-based regimens), with fat gain due to restoration to health in antiretroviral therapy-naive PLWH, which is compounded by the rising rates of obesity. The mechanisms of fat alterations in PLWH are complex, multifactorial and not fully understood, although they are known to result in part from the direct effects of HIV proteins and antiretroviral agents on adipocyte health, genetic factors, increased microbial translocation, changes in the adaptive immune milieu after infection, increased tissue inflammation and accelerated fibrosis. Management includes classical lifestyle alterations with a role for pharmacological therapies and surgery in some patients. Continued fat alterations in PLWH will have an important effect on lifespan, healthspan and quality of life as patients age worldwide, highlighting the need to investigate the critical uncertainties regarding pathophysiology, risk factors and management.

Biomarkers Associated with Death After Initiating Treatment for Tuberculosis and HIV in Patients with Very Low CD4 Cells

Background

The risk of short-term death for treatment naive patients dually infected with Mycobacterium tuberculosis and HIV may be reduced by early anti-retroviral therapy. Of those dying, mechanisms responsible for fatal outcomes are unclear. We hypothesized that greater malnutrition and/or inflammation when initiating treatment are associated with an increased risk for death.

Methods

We utilized a retrospective case-cohort design among participants of the ACTG A5221 study who had baseline CD4 < 50 cells/mm³. The case-cohort sample consisted of 51 randomly selected participants, whose stored plasma was tested for C-reactive protein, cytokines, chemokines, and nutritional markers. Cox proportional hazards models were used to assess the association of nutritional, inflammatory, and immunomodulatory markers for survival.

Results

The case-cohort sample was similar to the 282 participants within the parent cohort with CD4 <50 cells/mm³. In the case cohort, 7 (14%) had BMI < 16.5 (kg/m²) and 17 (33%) had BMI 16.5-18.5(kg/m²). Risk of death was increased per 1 IQR width higher of log₁₀ transformed level of C-reactive protein (adjusted hazard ratio (aHR) = 3.42 [95% CI = 1.33-8.80], P = 0.011), interferon gamma (aHR = 2.46 [CI = 1.02-5.90], P = 0.044), MCP-3 (3.67 [CI = 1.08-12.42], P = 0.037), and with IL-15 (aHR = 2.75 [CI = 1.08-6.98], P = 0.033) and IL-17 (aHR = 3.99 [CI = -1.06-15.07], P = 0.041). BMI, albumin, hemoglobin, and leptin levels were not associated with risk of death.

Conclusions

Unlike patients only infected with M. tuberculosis for whom malnutrition and low BMI increase the risk of death, this relationship was not evident in our dually infected patients. Risk of death was associated with significant increases in markers of global inflammation along with soluble biomarkers of innate and adaptive immunity.

Effects of HIV Infection on Body Composition Changes Among Men of Different Racial/Ethnic Origins

PURPOSE

To compare racial/ethnic differences and effects of HIV on body composition among antiretroviral (ART)-naïve HIV seropositive (HIV+) men to a representative sample of HIV seronegative (HIV-) men. We hypothesized that the effect of HIV infection will be uniform across all racial/ethnic groups.

METHOD

A cross-sectional analysis was performed comparing HIV- (NHANES 1999-2002) and ART-naïve HIV+ men (CPCRA 061). Regional subcutaneous fat area was estimated by skinfold caliper. Total body fat (TBF), fat-free mass (FFM), and body fat index (BFI) were derived by Durnin-Womersley formula (TBF-DW, FFM-DW, BFI [TBF-DW/height(2)]). Bioelectric impedance analyses (BIA) was used to assess TBF-BIA, FFM-BIA, and body cell mass (BCM). Multivariate regression modeling adjusted for age, smoking, and hepatitis C for each measurement was performed.

RESULTS

HIV+ men (n = 321) were older and more likely to be smokers than HIV- men (n = 1,996). The HIV- men were heavier in weight (+17.8 kg, p < .001) and had higher BMI (+4.3 kg/m(2), p < .001), BCM (+2.4 kg, p = .02), FFM (+5.9 kg, p < .001), TBF-DW (+5.95 kg, p < .001), BFI (+1.6 kg/m(2), p < .001), and regional fat mass than the HIV+ men. In the multivariate model, there were significant percentage differences between HIV- and HIV+ African American men for all body composition measurements (weight +15.3%; BMI +14.5%; BCM +5.2%; TBF-DW +15%; BFI 13.9%; FFM-DW 7.9%) and all circumference and skinfold measurements; all ps < .05. For Caucasian men, the following differences were significant between HIV- and HIV+: weight +14.4%; BMI +14.0%; BCM +6.0%; TBF-DW +17.7%; BFI 17.1%; FFM-DW 8.7%; and all circumference and skinfold measurements. Similarly, among Latino men the following differences were significant: weight +10.1%; BMI +12.3%; FFM-DW +7.7%; and arm, waist, and thigh circumferences and mid-arm skinfold fat area. The interaction terms for race/ethnicity were not significant across the three racial groups for weight, BMI, BCM, TBF-BIA, and BFI.

CONCLUSION

Compared to HIV uninfected men, among HIV-infected ART-naïve men there was a significant effect of HIV infection itself on body composition among all racial/ethnic groups.

HIV Wasting Syndrome in a Nigerian Failing Antiretroviral Therapy: A Case Report and Review of the Literature

The HIV wasting syndrome represented the face of HIV/AIDS before the advent of highly active antiretroviral therapy (HAART). Although the incidence of wasting has declined since the introduction of HAART, weight loss remains common in patients receiving HAART, especially in the setting of a failing HAART regimen. As we are not aware of any previous reports from Nigeria, we report a case of the classical wasting syndrome in a Nigerian female who had both virological and immunological HAART failure due to poor adherence. The influence of a failing HAART regimen, socioeconomic status, and other clinical variables in the wasting syndrome are discussed.

Nutritional status and serum zinc and selenium levels in Iranian HIV infected individuals

BACKGROUND

Human immunodeficiency virus infected individuals are prone to malnutrition due to increased energy requirements, enteropathy and increased catabolism. Trace elements such as zinc and selenium have major role in maintaining a healthy immune system. This study was designed to evaluate the nutritional status of Iranian subjects who were newly diagnosed with human immunodeficiency virus infection and to compare serum level of zinc and selenium in these patients with those of the sex and aged match healthy subjects.

METHODS

After an interview and physical examination, nutritional assessment was done based on clinical and anthropometric parameters. Body mass index (normal range 18.5-27 kg/m2 based on age) of less than 16, 16-16.9 and 17-18.4 kg/m2 were considered as severe, moderate and mild malnutrition respectively. Serum level of zinc and selenium were measured by graphite furnace atomic absorption.

RESULTS

Severe, moderate and mild malnutrition were detected in 15%, 38% and 24% of human immunodeficiency virus infected individuals respectively. Compared with the healthy control group, serum level of zinc and selenium in the human immunodeficiency virus infected subjects were significantly lower (P = 0.01 and P = 0.02 respectively).

CONCLUSION

Malnutrition found to be prevalent in Iranian human immunodeficiency virus infected individuals and low serum zinc and selenium levels are common in this population.

Evaluation of high-protein supplementation in weight-stable HIV-positive subjects with a history of weight loss: a randomized, double-blind, multicenter trial

BACKGROUND

HIV patients with wasting are at increased risk of opportunistic complications and fatality.

OBJECTIVE

We hypothesized that augmenting dietary intake with high-biologic-value protein would enhance weight and lean tissue in weight-stable subjects with a prior unintentional weight loss of >3%.

DESIGN

Fifty-nine subjects with HIV RNA concentrations <5000 copies/mL were randomly assigned to receive a 280-kcal supplement containing 40 g whey protein or a matched isocaloric control supplement without added protein twice daily for 12 wk.

RESULTS

Before the study, intake of total energy and protein exceeded estimated requirements (44.3 +/- 12.6 kcal x kg(-1) x d(-1) and 1.69 +/- 0.55 g x kg(-1) x d(-1), respectively). Both supplements failed to increase total energy intake because of decreases in self-selected food intake. Changes in weight (0.8 +/- 2.4 and 0.7 +/- 2.4 kg) and lean body mass (0.3 +/- 1.4 and 0.3 +/- 1.5 kg) did not differ significantly between the whey protein and control groups, respectively. Waist-to-hip ratio improved more with whey protein (-0.02 +/- 0.05) than with the control (0.01 +/- 0.03; P = 0.025) at week 6 but not at week 12. Fasting triacylglycerol increased by 39 +/- 98 mg/dL with the control supplement and decreased by 16 +/- 62 mg/dL with whey protein at week 12 (P = 0.03). CD4 lymphocytes increased by 31 +/- 84 cells/mm(3) with whey protein and decreased by 5 +/- 124 cells/mm(3) with the control supplement at 12 wk (P = 0.03). Gastrointestinal symptoms occurred more often with whey protein.

CONCLUSIONS

A whey protein supplement did not increase weight or lean body mass in HIV-positive subjects who were eating adequately, but it did increase CD4 cell counts. The control supplement with rapidly assimilable carbohydrate substituted for protein increased cardiovascular disease risk factors. Careful dietary and weight history should be obtained before starting nutritional supplements in subjects with stable weight loss and good viral control.

Care and treatment of HIV-infected children in Africa: issues and challenges at the district hospital level

More than 90% of pediatric HIV infection occurs in sub-Saharan Africa and 75% of these children currently die before their fifth birthday. Most HIV-infected children in Africa rely on district hospitals for HIV treatment, but insufficient attention has been paid to improving HIV/AIDS care at this level. Considerable confusion exists about optimal use of combination antiretroviral treatment, prophylaxis for opportunistic infections and other rational healthcare interventions that can greatly improve the quality of life for these children. A simple and inexpensive infant HIV diagnostic assay and alternative laboratory markers of pediatric HIV disease progression would be highly beneficial. Routine anthropometric and neurodevelopmental assessments could help guide initiation and monitoring of antiretroviral therapy. Even in the absence of antiretroviral therapy, interventions such as immunizations, provision of micronutrients and nutrition counseling, prevention and treatment of opportunistic as well as endemic infections (such as helminths and malaria) can substantially reduce pediatric HIV-related morbidity and mortality. The need for pain relief, palliative care, counseling and emotional support is often underestimated. Surmounting the sense of hopelessness by providing district healthcare workers with training in basic pediatric HIV/AIDS care is an urgent priority.

Counteracting muscle wasting in HIV-infected individuals

HIV-infected persons often experience a loss of lean tissue mass, which includes decreases in skeletal muscle mass. This HIV-associated wasting is significant because it has been associated with accelerated disease progression and increased morbidity. Signalling related to several circulating molecules, including tumour necrosis factor (TNF)-alpha, growth hormone, insulin-like growth factor (IGF)-1 and testosterone, has been associated with the aetiology of muscle wasting. Additionally, nutritional status related to malnutrition and specific dietary deficiencies may be involved. In an attempt to counter muscle wasting in HIV-infected persons, treatments have been suggested that target these mechanisms. Nutritional supplementation, cytokine reduction, hormone therapy and resistance exercise training are potential treatments for this condition. Resistance exercise training, which is more easily accessible to this population than other treatments, holds promise in counteracting the process of HIV wasting, as it has been successfully used to increase lean tissue mass in healthy and clinical populations. This review will explore the HIV/AIDS muscle-wasting syndrome, its aetiology, and the treatments used to counteract wasting.

Nutritional and metabolic abnormalities in pre-AIDS HIV infection

Since the earliest reports of human immunodeficiency virus (HIV) disease, undernutrition has been associated with HIV infection, typically with the late stages of the disease (namely acquired immunodeficiency syndrome), and may advance to severe wasting and cachexia. Specific micronutrient deficiencies are also recognized to occur with HIV infection, but their actual effect on the clinical course of the disease is hard to assess. The studies reviewed provide more insight into the complex interface between undernutrition and, in some cases, obesity and HIV/acquired immunodeficiency syndrome and highlight the possibility of alleviating or curing undernutrition by means of simple and comparatively inexpensive dietary adjustments.

Body mass index at time of HIV diagnosis: a strong and independent predictor of survival

BACKGROUND

Identification of basic prognostic indicators of HIV infection is essential before widespread antiretroviral therapy can be implemented in low-technology settings. This study assessed how well body mass index (BMI:kg/m2) predicts survival.

METHODS

BMI within 3 months of HIV diagnosis was obtained from 1657 patients aged > or = 15 years, recruited in a seroprevalent clinical cohort in The Gambia since 1992 and followed up at least once. Baseline CD4+ counts and clinical assessment at time of diagnosis were done.

RESULTS

The mortality hazard ratio (HR) of those with a baseline BMI <18 compared with those with a baseline BMI > or = 18 was 3.4 (95% CI, 3.0-3.9). The median survival time of those presenting with a BMI <16 was 0.8 years, in contrast to a median survival of 8.9 years for those with a baseline BMI > or = 22. Baseline BMI <18 remained a highly significant independent predictor of mortality after adjustment for age, sex, co-trimoxazole prophylaxis, tuberculosis, reported wasting at diagnosis, and baseline CD4+ cell count (adjusted HR = 2.5, 95% CI 2.0-3.0). Sensitivity and specificity of baseline BMI <18 was comparable to that of a CD4+ count <200 in predicting mortality within 6 months of diagnosis.

DISCUSSION

BMI at diagnosis is a strong, independent predictor of survival in HIV-infected patients in West Africa. In the absence of sophisticated clinical and laboratory support, BMI may also prove a useful guide for deciding when to initiate antiretroviral therapy.

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.

Sex differences in the associations of HIV disease characteristics and body composition in antiretroviral-naive persons

BACKGROUND

Data on associations of body composition with HIV disease characteristics are limited.

OBJECTIVE

We compared sex-specific associations between HIV disease characteristics and body composition in an racially-ethnically diverse cohort of antiretroviral-naive patients.

DESIGN

The study was a cross-sectional analysis of participants enrolled in a metabolic substudy of a multicenter trial. Regional fat was measured, and total body fat (TBF) was derived by using the Durnin-Womersley formula (DWF) and bioelectrical impedance analysis (BIA). Body cell mass (BCM) was measured by BIA.

RESULTS

Among 422 participants, 22% were women, 60% were African American, and 36% had prior AIDS-defining illnesses. Mean (+/-SD) age was 38.2 +/- 9.6 y, CD4+ count was 215 +/- 184 cells/mm3, and HIV RNA log10 was 5.0 +/- 0.8 copies/mL. On multivariate analysis, women with AIDS-defining illness had significantly (P < 0.005) lower regional body fat and TBF (BIA: -9.5 kg; DWF: -7.3 kg) but nonsignificantly lower BCM (-1.3 kg) than did women without such illnesses, whereas men with AIDS-defining illness had significantly (P < 0.005) lower BCM (-1.7 kg) but nonsignificantly lower TBF (BIA: -1.3 kg; DWF: -1.83 kg) than did men without such illnesses (P < 0.05 for sex differences in TBF). Significant negative associations of HIV RNA with BCM (-0.9 kg/log RNA; P = 0.03), TBF by BIA (-1.4 kg/log RNA; P = 0.05) and by DWF (-1.6 kg/log RNA; P = 0.01), and regional fat were observed in men only.

CONCLUSIONS

The effect of prior AIDS illness on body fat differed significantly between the sexes: women with prior AIDS-defining illness had significantly less fat than did women without such illnesses. An independent effect of HIV viremia on BCM and fat was seen in men. These distinctions may be due to inherent biological differences between the sexes.

Changes in Weight and Lean Body Mass during Highly Active Antiretroviral Therapy

BACKGROUND

Few studies have prospectively evaluated the impact of highly active antiretroviral therapy (HAART) on body weight and lean body mass (LBM) or explored the impact of baseline immunologic or virological changes on these parameters.

METHODS

Adult AIDS Clinical Trials Group (ACTG) protocol 892 was a prospective, 48-week, multisite observational study of body composition conducted during 1997-2000 among 224 antiretroviral-naive and antiretroviral-experienced subjects coenrolled into various adult ACTG antiretroviral studies. Assessments included human immunodeficiency virus type 1 (HIV-1) RNA load (by polymerase chain reaction); T lymphocyte subset analysis; Karnofsky score; height (baseline only); weight, LBM, and fat (by bioelectrical impedance analysis); and functional performance (by questionnaire).

RESULTS

Overall, only modest median increases in body weight (1.9 kg) and LBM (0.6 kg) occurred after 16 weeks of therapy. Significantly greater median increases in body weight (2.1 vs. 0.5 kg; P=.045) occurred in subjects who achieved virological suppression (HIV-1 RNA load, <500 copies/mL) at week 16 than in subjects who did not. Subjects who were antiretroviral naive at baseline gained more weight (median increase in body weight, 2.6 vs. 0.0 kg; P<.001) and LBM (1.0 vs. 0.1 kg; P=.002) after 16 weeks of treatment than did subjects who were antiretroviral experienced. Subjects with lower baseline CD4 cell counts (<200 cells/mm3) and subjects with higher baseline HIV-1 RNA loads (> or =100,000 copies/mL) were more likely to show increases in LBM of >1.5 kg (P=.013 and P=.005, respectively).

CONCLUSIONS

HAART had modestly favorable effects on body composition, particularly in patients with greater pretreatment immunocompromise and virological compromise. The difference between antiretroviral-naive and antiretroviral-experienced subjects with regard to the ability to achieve increased body weight and LBM requires more study.

Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection

Infection with the human immunodeficiency virus (HIV) and the development of acquired immunodeficiency syndrome (AIDS) have had a significant impact on domestic and global health, social, political, and economic outcomes. Prevention and treatment efforts to control HIV infection are more demanding than in previous decades. Achieving food and nutrition security, and managing nutrition-related complications of HIV infection and the multiple aspects of disease initiated by or surrounding HIV infection, referred to as HIV disease, remain challenges for patients and for those involved with HIV/AIDS prevention, care, and treatment efforts. Confounding clinical issues include medication interactions, coinfection with other infections and diseases, wasting, lipodystrophy, and others. Dietetics professionals, other health care professionals, and people infected with HIV will need to understand and address multiple complex aspects of HIV infection and treatment to improve survival, body functions, and overall quality of life. Individualized nutrition care plans will be an essential feature of the medical management of persons with HIV infection and AIDS.

HIV-1 viral load and elevated serum alpha(1)-antichymotrypsin are independent predictors of body composition in pregnant Zimbabwean women

Human immunodeficiency virus (HIV) infection affects body composition, but their relationship has not been studied in pregnant women. We conducted a cross-sectional study among 1669 women receiving antenatal care between 22 and 35 wk of gestation in Harare, Zimbabwe. The role of HIV-1 status and viral load, malaria and elevated serum alpha(1)-antichymotrypsin (ACT, an acute phase protein) in weight, body mass index (BMI), arm circumference (AC), triceps skinfold thickness (TSF), and arm muscle (AMA) and fat (AFA) area were assessed using multiple linear regression analysis. The mean (range) age was 24.4 (14-45) y and gestational age 29 (22-35) wk. HIV infection was present in 31.5% of the women, malaria parasitemia in 0.4% and 11.4% had serum ACT >0.4 g/L. There was no difference in any anthropometric variable between HIV-infected and uninfected women. However, women with viral loads (genome equivalents/mL) between 4 and 5 and >5 log(10) had 1.1 [95% confidence interval (CI): -0.3, 2.3] and 2.5 (95% CI: 0.1, 5.1) kg lower weights compared with uninfected women; this was explained by losses of both AFA and AMA. Malaria parasitemia was associated with 6 cm(2) (95% CI: 0.4; 11.8) or 25% lower AMA. Elevated serum ACT was a negative predictor of all anthropometric variables, i.e., levels between 0.3 and 0.4, 0.4 and 0.5 and >0.5 g/L were associated with 1, 2 and 6 kg lower mean body weights, respectively. Despite the limitations of a cross-sectional design, we conclude that arm fat and muscle areas, reflecting body fat and lean body mass, seem to be unaffected in the majority of HIV-infected pregnant women, but decline with increasing viral loads. The effects of viral load are not explained by elevated serum ACT, which is a strong independent predictor of all anthropometric variables.

Urinary cytokines for assessing inflammation in HIV-associated wasting

The relationship between cytokines and HIV-related weight loss has not been well established. Unlike most cytokines that are secreted in a paracrine manner, IL-6, sTNFR-II, and IL-1ra are readily detected in the systemic circulation and serve as markers of the inflammatory response. Twenty-four-hour urine concentrations of these proteins are believed to provide an integrative assessment of their systemic levels over the preceding hours. We sought to determine whether spot measurements of IL-6, sTNFR-II, and IL-1ra could be related to subsequent 24 h concentrations and prior weight loss. Eighteen subjects with severe wasting (average BMI=18+/-3 kg/m2with 19+/-13 kg of weight loss) and six HIV-negative healthy subjects were tested. Compared to values in controls, 24-h urinary concentrations of the three proteins adjusted for creatinine excreted were elevated in 44%, 89%, and 72% of patients, respectively. Twenty-four-hour concentrations were highly correlated with the spot concentrations (r=0.80, 0.87, 0.84, respectively, P<0.001). IL-1ra concentrations (24 h and spot) were correlated with weight loss in the previous 6 months, lifetime rate of weight loss and the 6 month rate of weight loss (spot: r=0.66, 0.73, 0.68, respectively, P< or =0.001). These data suggest that spot urinary collections can be used to estimate 24 h excretion rates. This strategy may be useful in assessing the inflammatory response in HIV-associated wasting.

HIV-associated wasting: brief review and discussion of the impact of oxandrolone

This is a brief review of human immunodeficiency virus (HIV)-associated wasting with expanded discussion of one treatment agent, oxandrolone. HIV-associated wasting is the involuntary loss of more than 10% of baseline body weight in the presence of chronic diarrhea, weakness, or fever lasting longer than 30 days. For patients, this clinical syndrome has special importance because it affects not only their survival but also their physical appearance and social interactions. Pharmacologic treatment is only one of the many approaches that need to be explored in every patient who presents with this condition. In 1964, oxandrolone became the first drug approved for the treatment of wasting. Since then its role has expanded to HIV-associated wasting. As an anabolic agent oxandrolone reverses many of the metabolic abnormalities characteristic of HIV-associated wasting leading to dose dependent increase in nitrogen retention. Similar to many other HIV treatments, gaps exist in our knowledge of the role of oxandrolone in HIV-associated wasting. These gaps will be filled only by years of field exposure and further clinical research.

Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection

Human immunodeficiency virus (HIV) targets the immune system, making an infected person susceptible to infection and neoplasm because of an impaired ability to mount an adequate immune response. Malnutrition and its complications can further render an HIV-infected person susceptible to opportunistic infection and reduced effectiveness and tolerance to medications and other therapies. Though effective antiretroviral treatments have dramatically reduced death rates in the United States and Canada, HIV-infected people face a lifetime of vigilant polypharmacy to control HIV and associated complications. Malnutrition, various forms of tissue wasting, fat accumulation, increased lipid levels, and risk of additional chronic disease have become central issues in health care plans. It is the position of the American Dietetic Association and Dietitians of Canada that efforts to optimize nutritional status, including medical nutrition therapy and nutrition-related education, should be components of the total health care provided to people infected with human immunodeficiency virus HIV.

Virologic, immunologic, and immune activation markers as predictors of HIV-associated weight loss prior to AIDS. Multicenter AIDS Cohort Study

OBJECTIVES

To study weight patterns among HIV-positive men and associations of baseline HIV RNA, CD4+ lymphocyte count, and serum levels of neopterin and beta2-microglobulin with subsequent weight loss prior to AIDS.

METHODS

A cohort of 1558 homosexual men from the Multicenter AIDS Cohort Study comprised the main study population. Marker values obtained using samples from a baseline visit in 1984 to 1985 were associated with weight patterns and risk of weight loss events over 10 years of follow-up. To investigate the impact of protease inhibitor (PI) therapy on weight patterns, a separate analysis was conducted for men who initiated such therapy in 1995 to 1996.

RESULTS

In general, HIV-positive men demonstrated a striking tendency toward weight loss, with a rate of decline that increased over time. Distinct variations in this pattern were observed according to baseline HIV RNA levels. Each marker considered was independently predictive of weight loss events. Following use of PIs, 68 men showed a tendency toward increased weight, compared with men who did not use PIs.

CONCLUSIONS

Although baseline virologic, immunologic, and immune activation markers all predicted weight loss events in AIDS-free HIV-positive men, HIV RNA displayed the best discrimination. Shifts in weight patterns observed in this cohort after PI therapy call for further attention to nutritional and body changes as the duration of therapy increases.

Predictive markers of HIV-related weight loss and determination of differences between populations with weight loss stratified by opportunistic processes

OBJECTIVE

To describe factors predictive of >10% weight loss among enrolled participants in clinical trials of the AIDS Clinical Trial Group (ACTG).

DESIGN

A retrospective analysis of data from selected ACTG antiretroviral clinical trials completed prior to 1996 (ACTG 116, 117, 155, 175, and 241), which did not include protease inhibitors.

METHODS

Data were analyzed in Cox proportional hazards models to determine significant predictors for >10% weight loss while on study. Weight loss occurring within 30 days before or after an opportunistic infection (OI) was defined as "OI-associated." Both univariate and multivariate models were considered; gender-specific models were also analyzed to provide insight into potential gender differences in predictors of weight loss.

RESULTS

We found that substantial weight loss is a frequent occurrence among those enrolled in clinical trials of antiretroviral agents; approximately 15% of subjects in the studies considered experienced >10% weight loss. CD4 cell count and HIV-1 RNA at week 8, Karnofsky score, and injection drug use status were significant multivariate predictive markers for weight loss associated with an OI; baseline weight, hemoglobin, triglycerides, and gender were additional predictors for weight loss not associated with an OI.

CONCLUSIONS

This is the first study to characterize the association between baseline viral load and future weight loss. Baseline and week 8 immunologic parameters as well as measures of baseline symptomatology were significant predictors of weight loss associated and not associated with an OI.

Elevated resting energy expenditure among HIV-seropositive persons receiving highly active antiretroviral therapy

OBJECTIVES

To ascertain the relationships between resting energy expenditure (REE), HIV RNA in plasma, and highly active antiretroviral therapy (HAART).

DESIGN

Cross-sectional analysis using data of a large cohort study of nutrition in relation to HIV disease.

METHODS

HIV RNA in plasma, REE, fat-free mass (FFM), and medication regimens were assessed at 530 visits among 372 participants in a cohort study of HIV-seropositive men and women.

RESULTS

HIV RNA in plasma was directly correlated with REE. After adjustment for FFM, age, CD4 cell count and HAART use, there was an increase in REE of 90 kJ/day per log10 copies/ml increase in HIV RNA [95% confidence interval (CI) 16-164; P = 0.02). HAART use had an independent effect on REE. In patients reporting HAART use, adjusted REE was 339 kJ/day higher than in those not reporting HAART use (95% CI 177-501; P = 0.0001).

CONCLUSIONS

Viral load and HAART appear to exert independent effects on REE. Although HAART may decrease metabolic rate by lowering viral burden, it appears to increase metabolic demands through some mechanism(s) independent of its effect on viral burden. This may result in elevated REE despite control of viral replication.

Fat distribution in HIV-infected patients reporting truncal enlargement quantified by whole-body magnetic resonance imaging

BACKGROUND

Antiretroviral therapy has improved the prospects for people infected with HIV, but some develop a syndrome of profound body habitus and metabolic alterations that include truncal enlargement.

OBJECTIVE

The purpose of this study was to define the body-composition changes associated with this syndrome by using techniques with the power to estimate regional body composition.

DESIGN

We compared whole-body and regional skeletal muscle and adipose tissue contents measured by magnetic resonance imaging and dual-energy X-ray absorptiometry (DXA) in 26 HIV-infected patients and 26 matched control subjects. Twelve of the HIV-infected patients had evidence of truncal enlargement.

RESULTS

HIV-infected men and women who noted truncal enlargement had similar amounts of skeletal muscle and subcutaneous adipose tissue but greater visceral adipose tissue than HIV-infected patients without truncal enlargement; these values were larger in men (P < 0.001) than in women (P = 0.08). The ratio of visceral to subcutaneous adipose tissue was greater in both men (P < 0.02) and women (P = 0.05) with truncal enlargement. Two subjects with MRI-confirmed visceral adiposity syndrome (VAS) were not taking protease inhibitors. CD4+ lymphocyte counts were higher (P < 0.001) and plasma viral burdens tended to be lower (P = 0.08) in HIV-infected patients with VAS.

CONCLUSIONS

There was significantly more visceral adipose tissue in the subgroup of HIV-infected patients with truncal enlargement than in those without this sign. VAS occurs in both men and women, is associated with higher CD4+ lymphocyte counts and lower plasma HIV viral burdens, and is not limited to those receiving protease inhibitor therapy.