Treatment guidelines for HIV-associated wasting

Are cannabinoids effective for HIV wasting syndrome?

INTRODUCTION

Wasting syndrome is a common problem in HIV. It leads to substantive morbidity and mortality. The use of cannabinoids has been suggested as a treatment for weight, but it is not clear whether they are really safe and effective.

METHODS

To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified eight systematic reviews including ten studies overall, of which six were randomized trials. We concluded it is not clear whether cannabinoids increase appetite or weight in HIV wasting syndrome because the certainty of the evidence is very low, and they probably lead to frequent adverse effects.

Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement

Despite the high prevalence of performance-enhancing drug (PED) use, media attention has focused almost entirely on PED use by elite athletes to illicitly gain a competitive advantage in sports, and not on the health risks of PEDs. There is a widespread misperception that PED use is safe or that adverse effects are manageable. In reality, the vast majority of PED users are not athletes but rather nonathlete weightlifters, and the adverse health effects of PED use are greatly underappreciated. This scientific statement synthesizes available information on the medical consequences of PED use, identifies gaps in knowledge, and aims to focus the attention of the medical community and policymakers on PED use as an important public health problem. PED users frequently consume highly supraphysiologic doses of PEDs, combine them with other PEDs and/or other classical drugs of abuse, and display additional associated risk factors. PED use has been linked to an increased risk of death and a wide variety of cardiovascular, psychiatric, metabolic, endocrine, neurologic, infectious, hepatic, renal, and musculoskeletal disorders. Because randomized trials cannot ethically duplicate the large doses of PEDs and the many factors associated with PED use, we need observational studies to collect valid outcome data on the health risks associated with PEDs. In addition, we need studies regarding the prevalence of PED use, the mechanisms by which PEDs exert their adverse health effects, and the interactive effects of PEDs with sports injuries and other high-risk behaviors. We also need randomized trials to assess therapeutic interventions for treating the adverse effects of PEDs, such as the anabolic-androgen steroid withdrawal syndrome. Finally, we need to raise public awareness of the serious health consequences of PEDs.

Therapeutic effects of nandrolone and testosterone in adult male HIV patients with AIDS wasting syndrome (AWS): a randomized, double-blind, placebo-controlled trial

PURPOSE

We aimed to compare therapeutic effects of intramuscular (IM) nandrolone decanoate and IM testosterone enanthate in male HIV patients with AIDS wasting syndrome (AWS) with placebo control.

METHODS

In this randomized, double-blind, placebo-controlled, 12-week trial, 104 patients with AWS who satisfied our inclusion criteria were randomly allotted in a 2:2:1 ratio to the 3 intervention groups: nandrolone, testosterone, and placebo. We administered 150 mg nandrolone and 250 mg testosterone (both IM, biweekly). The primary outcome measure was a comparison of absolute change in weight at 12 weeks between the nandrolone decanoate, testosterone, and placebo groups.

RESULTS

Intent-to-treat analysis was done. The nandrolone group recorded maximum mean increase in weight (3.20 kg; post hoc P < .01 compared to placebo). Body mass index (BMI) of subjects in the nandrolone group had a significantly greater increase (mean = 1.28) compared to both testosterone (post hoc P < .05) and placebo (post hoc P < .01). Waist circumference and triceps skinfold thickness of patients on nandrolone showed similar results. Nandrolone also ensured a better quality of life. Patients with low testosterone level (<3 ng/mL) benefited immensely from nandrolone therapy, which increased their weight and BMI significantly compared to placebo (P < .05).

CONCLUSION

Our trial demonstrates the superior therapeutic effects of nandrolone in male AWS patients, including the androgen deficient.

The value of serum albumin in pretreatment assessment and monitoring of therapy in HIV/AIDS patients

OBJECTIVES

We sought to examine the utility of serum albumin measurement in staging AIDS and monitoring patients' response to therapy.

METHODS

The possible importance of serum albumin measurement in assessing AIDS stage and in monitoring the response to highly active antiretroviral therapy using CD4 cell count and body weight as parameters was examined in 185 consecutive HIV-infected, therapy-naïve individuals who were recruited for antiretroviral therapy at the university of Ilorin Teaching Hospital. The regimen included lamivudine, stavudine and nevirapine. The diagnosis of AIDS was established through a combination of clinical features and HIV seropositivity using two different enzyme-linked immunosorbent assay techniques. Serum albumin level was determined by the Bromocresol green method, while the CD4 lymphocyte count was obtained using the Dynal T4 count method. Body weight was measured in kilograms with light clothes on.

RESULTS

There were significant positive correlations between pretreatment albumin and both pretreatment CD4 cell count and pretreatment weight, and between post-treatment albumin and both post-treatment weight and post-treatment CD4 cell count up to a count of 700 cells/microL. There were also significant positive correlations between increase in serum albumin and both increase in body weight and duration of treatment.

CONCLUSIONS

We conclude that, in developing countries where many patients may not be able to afford to pay for CD4 cell counts and viral load tests, which are the traditional markers for HIV disease, serum albumin would be a very useful surrogate test for predicting severity of HIV infection and for clinical monitoring of response to antiretroviral therapy.

The Impact of Nutrition on Physiologic Changes in Persons Who Have HIV

HIV affects almost all bodily systems, which can lead to recurrent opportunistic infections, weight loss, distribution of weight changes, and death. Malnutrition and wasting, two symptoms that interfere with nutrient availability, accessibility, and metabolism, are associated with higher morbidity and mortality. Nausea, vomiting, swallowing or chewing difficulties, or the response of the body to opportunistic infections or medications that are considered vital to the treatment of the disease may affect nutritional status. A positive nutritional balance may help to improve the immune and other body systems, and delay the progression of the disease, This article reviews the effect of the nutritional status on the physiologic changes in the person who is infected with HIV.

Mammalian cell-derived somatropin : a review of its use in the management of HIV-associated wasting

HIV-associated wasting, characterised by progressive loss of lean body mass and bodyweight, remains a significant problem in the era of highly active antiretroviral therapy (HAART). Loss of body cell mass, a component of lean body mass, is associated with decreased survival. Somatropin (recombinant human growth hormone) derived from mammalian cells (Serostim) is the only US FDA-approved treatment indicated to increase lean body mass, bodyweight and physical endurance in HIV-associated wasting. Somatropin 0.1 mg/kg/day administered subcutaneously for 12 weeks effectively increased work output, bodyweight and lean body mass and improved health-related quality of life (HR-QOL), compared with placebo, and had a generally manageable tolerability profile in a large randomised study in patients with HIV-associated wasting. Potential areas for further research include determination of longer-term efficacy and tolerability, the cost effectiveness of treatment, the optimal somatropin dosage, management of patients after 12 weeks' therapy and whether maintenance strategies might exist to maintain accrued lean body mass with lower doses of somatropin. Nevertheless, indications to date are that somatropin is likely to have an important role in the treatment of patients with HIV-associated wasting.

High prevalence of adrenal suppression during acute illness in hospitalized patients receiving megestrol acetate

INTRODUCTION

Megestrol acetate (MA) is a progestational agent used for palliation of breast and endometrial cancer. The drug promotes weight gain via appetite stimulation. This property has led to widespread use in patients with wasting illnesses. Increasing numbers of reports suggest glucocorticoid activity.

OBJECTIVE

Unrecognized adrenal suppression may result from MA use. This is the first study to examine the prevalence of adrenal suppression in hospitalized patients treated with MA.

SUBJECTS AND DESIGN

This is a cross-sectional study of hospitalized patients receiving MA compared to control subjects. Morning cortisol levels, endocrine signs and symptoms, and duration of MA therapy were evaluated in 28 hospitalized medical patients treated with MA, and 21 control patients admitted to the same hospital service during the study period.

RESULTS

Median cortisol levels were significantly lower in patients using MA vs controls (160 vs 386 nmol/l, p=0.003). Forty-three percent of subjects on MA demonstrated morning cortisol levels below the normal range (138-690 nmol/l), compared with 10% of controls (p=0.013). Ninety-three percent of subjects taking MA had morning cortisol levels below the level that excludes adrenal insufficiency in hospitalized patients (497 nmol/l) vs 71% of controls (p=0.06).

CONCLUSIONS

MA use is associated with significant adrenal suppression in acutely ill individuals. This should alert physicians to the possibility of adrenal insufficiency and the need to assess for signs or symptoms of adrenal insufficiency, and mandates a low threshold for testing adrenal function in hospitalized patients taking MA.

Treatment of unintentional weight loss in patients with cancer

Malnutrition from anorexia and reduced nutrient intake is common in patients with cancer. Abnormalities in gastrointestinal function caused by the tumor or treatment of the tumor may be direct causes for nutrition challenges. However, other patients may present with cancer cachexia, a wasting syndrome characterized by weight loss, anorexia, early satiety, progressive debilitation, and malnutrition that results in a greater risk of organ dysfunction and death. Changes in host metabolism and energy expenditure are thought to contribute to the development of cachexia, although this relationship is not clear. There is evidence that the etiology of these metabolic changes may be mediated by a neurohormonal response stimulated by the tumor. Because a single cause for these metabolic abnormalities has not been identified, several approaches to treatment of cancer cachexia have been reported. After correction of any underlying gastrointestinal abnormalities, single nutrients or other pharmacologic agents have been used in an attempt to favorably affect appetite or counter metabolic abnormalities that cause inefficient nutrient use. A variety of agents have been studied for their positive effects on appetite, including progestational agents, glucocorticoids, cannabinoids, cyproheptadine, olanzapine, and mirtazapine. Other agents have been investigated for their anti-inflammatory properties, including thalidomide, pentoxyphylline, melatonin, and omega-3 fatty acids. Anabolic agents such as testosterone derivatives have been investigated as well. The decision to treat symptoms of cancer cachexia should be based on the patient's desires and current medical condition. Choice of the most appropriate agent to treat unintentional weight loss in patients with cancer should include consideration of effects on appetite, weight, quality of life, and risk of adverse effects according to current evidence-based medicine, and cost and availability of the agent.

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.

Efficacy of Selected Treatments of HIV Wasting

PURPOSE

To assess the efficacy of recombinant human growth hormone (rhGH), testosterone, and anabolic steroids in the treatment of HIV wasting.

METHODS

A systematic review and meta-analysis of studies published in English since 1996 was conducted. Studies of anabolic steroids, testosterone, and rhGH in treatment of HIV wasting reporting the efficacy outcomes of body composition measures, work output, or health-related quality of life (QoL) were eligible. Meta-analyses were performed for mean pre-post change in lean body mass (LBM), the within-study mean difference in pre-post change for LBM, and of odds ratios for certain safety events.

RESULTS

A total of 18 studies met inclusion criteria for this review.

CONCLUSION

The 3 treatments for HIV wasting assessed--rhGH, testosterone, and anabolic steroids--all demonstrated significant efficacy in increasing LBM as compared with placebo. Although meta-analysis did not indicate any statistically significant differences between these agents in the degree of efficacy in this outcome, the Food and Drug Administration-approved dose of rhGH may have advantages over the other 2 therapies in terms of improvements in functional capacity and QoL.

Collaborative Recommendations

Loss of lean body mass in patients with HIV, commonly referred to as wasting, remains a significant threat to outcome in the era of highly active antiretroviral therapy. It does not require advanced immune deficiency to progress. It is appropriate to reevaluate guidelines for diagnosis and treatment of wasting in the context of the increasing detail with which the risks and causes of HIV wasting are being understood. A wide range of therapies can be effective in preventing weight loss, but the pharmacologic options for restoring body cell mass, a key measure of HIV wasting, are far more limited. A collaborative meeting of clinicians and researchers with an interest in HIV wasting was held to evaluate published guidelines in the context of current clinical data.

The Use of Custom-Designed Midfacial and Submalar Implants in the Treatment of Facial Wasting Syndrome

Facial wasting syndrome is part of a lipodystrophy that occurs as a complication of highly active antiretroviral therapy. The loss of subcutaneous fat in the cheeks and temples results in a hollow-eyed, bony, emaciated appearance that is characteristic of the results of treatment of human immunodeficiency virus. Cessation of therapy results in a rebound in viral load and subsequent morbidity. The appearance of facial wasting syndrome is optimally treated with custom-designed implants that are made using high-resolution computed tomography combined with surgeon input and computer-aided design and manufacturing technology. Twenty-two patients with facial wasting syndrome were treated using either submalar implants (in more moderate cases) or custom-designed implants (in more severe cases). In each patient, the appearance of volumetric soft tissue restoration was successfully achieved, returning a permanent and more healthful appearance to the face.

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.

Growth Hormone Improves Lean Body Mass, Physical Performance, and Quality of Life in Subjects With HIV-Associated Weight Loss or Wasting on Highly Active Antiretroviral Therapy

HIV-associated wasting is defined as > or = 10% involuntary weight loss and includes declines in both lean and fat mass. This large (757 subjects), randomized, double-blind, placebo-controlled trial investigated the efficacy, safety, and tolerability of recombinant human growth hormone (rhGH) in 2 doses-0.1 mg/kg up to a maximum of 6 mg daily (DD) or alternate days (AD)-in the treatment of wasting and weight loss in highly active antiretroviral therapy (HAART)-treated HIV-infected subjects. The evaluable population for ergometry comprised 555 subjects, 87.6% of whom were receiving HAART. At 12 weeks, median maximum work output increased by 2.4 and 2.6 kJ in the AD and DD groups, respectively. The median treatment difference was 2.9 kJ for DD vs. placebo (P < 0.0001). Body weight increased by 2.2 and 2.9 kg in the AD and DD groups, respectively. Corresponding median treatment differences vs. placebo were 1.5 and 2.2 kg (P < 0.0001). Lean body mass (LBM), by bioelectric impedance spectroscopy, increased by 3.3 and 5.2 kg, respectively (P < 0.0001 vs. placebo; P = 0.0173 DD vs. AD), and fat mass, predominately truncal, decreased. Quality of life (QoL) improved significantly in both rhGH groups. Fluid-retention adverse effects and hyperglycemia were more common in the DD than in the AD group. No significant changes in HIV viral load or CD4 cell count occurred. In conclusion, over the 12-week course of therapy, rhGH, 0.1 mg/kg DD, was superior to placebo in improving physical function, body weight, body composition, and QoL and was superior to AD dosing in restoring LBM.

Comparing Megestrol Acetate Therapy with Oxandrolone Therapy for HIV‐Related Weight Loss: Similar Results in 2 Months

Weight loss is known to impact survival among patients infected with human immunodeficiency virus (HIV) even in the era of highly active antiretroviral therapy (HAART). In a randomized trial, we compared the effects of 2 months of treatment with either megestrol acetate (800 mg every day) or oxandrolone (10 mg twice per day) on body weight and composition in patients with weight loss of > or =5 kg who were receiving HAART. The mean weight was 66 kg, and the mean body mass index was 21. Mean weight gain in the megestrol acetate and the oxandrolone arms were 2.8 kg (4.6% of the baseline value) and 2.5 kg (3.9% of the baseline value), respectively (P=.80). Lean body mass accounted for 39% of weight gain in the megestrol acetate arm and 56% in the oxandrolone arm (P=.38). Seven patients in the megestrol acetate arm and 5 patients in the oxandrolone arm reported minor adverse events (P=.74). In conclusion, megestrol acetate therapy and oxandrolone therapy have similar effects on body weight and composition and are safe and well-tolerated during HAART.

AIDS wasting syndrome: trends, influence on opportunistic infections, and survival

The authors examined data from a large cohort of HIV-infected persons to demonstrate recent trends in wasting syndrome, to examine the influence of wasting syndrome on the incidence of other opportunistic illnesses, and to explore if any of the commonly prescribed treatments for wasting are associated with improved survival. Kaplan-Meier analysis and multivariate left-truncated Cox models were used to estimate time to death after the first diagnosis of wasting syndrome and to quantify the association between the covariate and mortality, respectively. The incidence of wasting declined during 1992 through 1999, with the most marked rate of decline occurring after 1995. The incidence of AIDS- and non-AIDS-defining illnesses was generally high at or after a diagnosis of wasting syndrome. Factors significantly associated with improved survival include having a CD4+ count of > or =200 cells/L during the interval of the wasting syndrome diagnosis and antiretroviral therapy with two or more drugs at or after the diagnosis of wasting syndrome. Prescription of oxandrolone was associated with improved survival, but the results did not quite reach statistical significance. The authors' study provides supportive information that treatment of wasting syndrome may have a favorable impact on survival.

Double-blind, randomized, placebo-controlled phase III trial of oxymetholone for the treatment of HIV wasting

BACKGROUND

Despite highly active antiretroviral therapy (HAART), chronic involuntary weight loss still remains a serious problem in the care of HIV patients. Various alterations in energy metabolism and endocrine regulation have been found to cause loss of lean body mass (LBM) and body cell mass (BCM). Previous studies in HIV-positive men undergoing androgen replacement therapy or treatment with recombinant growth hormone (rGH) have shown partial restoration of LBM, but these treatments have largely been ineffective in eugonadal individuals.

STUDY DESIGN

Double-blind, randomized, placebo-controlled trial of 89 HIV-positive women and men with wasting assigned to the anabolic steroid oxymetholone [50 mg twice (BID) or three times daily (TID)] or placebo for 16 weeks followed by open-label treatment. STUDY ENDPOINTS: Body weight, bioimpedance measurements, quality of life parameters and appetite.

RESULTS

Oxymetholone led to a significant weight gain of 3.0 +/- 0.5 and 3.5 +/- 0.7 kg in the TID and BID groups, respectively (P < 0.05 for each treatment versus placebo), whereas individuals in the placebo group gained an average of 1.0 +/- 0.7 kg. Body cell mass increased in the oxymetholone BID group (3.8 +/- 0.4 kg; P < 0.0001) and in the oxymetholone TID group (2.1 +/- 0.6 kg; P < 0.005), corresponding to 12.4 and 7.4% of baseline BCM, respectively. Significant improvements were noted in appetite and food intake, increased well-being and reduced weakness by self-examination. The most important adverse event was liver-associated toxicity. Overall, 35% of patients in the TID, 27% of patients in the BID oxymetholone group and no patients in the placebo group had a greater than five times baseline increase for alanine aminotransferase during the double-blind phase of the study.

CONCLUSIONS

Oxymetholone can be considered an effective anabolic steroid in eugonadal male and female patients with AIDS-associated wasting. The BID (100 mg/day) regimen appeared to be equally effective as the TID (150 mg/day) regimen in terms of weight gain, LBM and BCM and was associated with less, but still significant liver toxicity.

Natural bovine lentiviral type 1 infection in Holstein dairy cattle. I. Clinical, serological, and pathological observations

Clinical, serological, and pathological abnormalities observed in Holstein cows naturally infected with bovine lentivirus 1 bovine immunodeficiency virus (BIV) and other infections were progressive and most commonly associated with weight loss, lymphoid system deficiency, and behavioral changes. Clinical evidence of meningoencephalitis was dullness, stupor, and occasional head or nose pressing postures. The polymerase chain reactions associated the BIV provirus with the lesions in the central nervous system and lymphoid tissues. Multiple concurrent infections developed in retrovirally infected cows undergoing normal stresses associated with parturition and lactation. A major functional correlate of the lymphoreticular alterations was the development of multiple secondary infections which failed to resolve after appropriate antibacterial therapy. The chronic disease syndrome in dairy cows associated with BIV may be useful as a model system for investigation of the pathogenesis of the nervous system lesions and lymphoid organ changes that occur in humans with lentiviral infection.

Testosterone therapy in HIV wasting syndrome: systematic review and meta-analysis

Many HIV patients develop weight loss, which increases morbidity and mortality. We aimed to assess the effects of testosterone therapy on lean body mass, total body weight, over-all exercise functional capacity, and perceived quality of life in patients with HIV wasting syndrome and its adverse effects. We systematically reviewed randomised, placebo-controlled trials that compared the effects of testosterone therapy with placebo in HIV patients with wasting. Eight trials met the inclusion criteria and 417 randomised patients were included. Only six trials used lean-body mass, fat-free mass, or body-cell mass as outcome measures. The meta-analysis of the six trials showed a difference in the lean body mass between the testosterone group and placebo group of 1.22 kg (95% CI 0.23-2.22) for the random effect model and 0.51 kg (0.09-0.93) for fixed effect. However, the difference was much greater in the three trials that used the intramuscular route-3.34 kg in the post-hoc analysis. All eight trials included total body weight as an outcome measure, the meta-analysis of which showed a difference of 1.04 kg (-0.01-2.10) between testosterone group and placebo group by random effect and 0.63 kg (-0.01-1.28) for fixed effect models. Over-all, the incidence of adverse effects is similar in both groups. Testosterone therapy has been shown in this review to increase lean body mass more than placebo. The increase is even greater if the therapy is given intramuscularly. There is also a small positive effect in total body weight. The study is, however, limited by the small numbers and heterogeneity of the population, which potentially introduced bias into the methods and results. Testosterone therapy may be considered in patients with HIV wasting syndrome to reverse muscle loss, but there is a concern about the adverse metabolic effects of long-term testosterone administration and long-term follow-up for these patients is needed.

Guidelines for using body composition measurement in patients with human immunodeficiency virus infection

Wasting remains a significant condition of human immunodeficiency virus (HIV) infection despite antiretroviral treatment. Early identification requires the measurement of various body composition parameters, particularly body cell mass (BCM). Anthropometry may provide some useful information. Cost and complexity issues make many body composition techniques unsuitable for the clinical setting. Bioelectrical impedance analysis (BIA) may be the best method available to caregivers for monitoring serial changes in BCM over time and for determining the occurrence of wasting. It is not useful, however, for detecting body composition changes in patients with fat redistribution syndromes. Portability, low cost, ease of use, and patient acceptance make anthropometry and BIA ideally suited for the clinical setting.

Biology of anemia, differential diagnosis, and treatment options in human immunodeficiency virus infection

Anemia is the most common hematologic manifestation of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome. The causes of HIV-related anemia are multifactorial and include direct and indirect effects of HIV infection. HIV-related anemia generally is due to reduced red blood cell (RBC) production, secondary to a variety of causes, but it may also involve nutritional deficiencies, increased RBC destruction, or a combination of these problems. Evaluation of hemoglobin level, reticulocyte count, bilirubin, and mean corpuscular volume value and review of the peripheral blood smear are necessary for diagnosis. Treatment of HIV-related anemia should address the correctable underlying causes of this disorder, such as modifications of offending medications, nutritional deficiencies, and parvovirus infection. Patients with HIV infection have a blunted erythropoietin response to anemia. Therapeutic modalities for anemia that is not amenable to correction include blood transfusion and recombinant human erythropoietin (epoetin alfa).

Differential effects of oral estrogen versus oral estrogen-androgen replacement therapy on body composition in postmenopausal women

Menopause is associated with decreased lean body mass and increased fat due to aging and declining hormone secretion. Estrogens or estrogen-progestins have been used to alleviate vasomotor symptoms. However, estrogen-androgen (E/A) therapy is also used for vasomotor symptom relief and has been shown to increase lean body mass while decreasing fat mass. The objective of this 16-wk, double-blind, randomized, parallel group clinical trial was to compare esterified estrogen plus methyltestosterone (1.25 mg estrogen + 2.5 mg methyltestosterone/d; E/A group) vs. esterified estrogen alone (1.25 mg/d; E group) on body composition. Forty postmenopausal women (mean age, 57 yr) participated. Compared with estrogen treatment alone, women in the E/A group increased their total lean body mass and reduced their percentage fat for all body parts (P < 0.05). After E/A treatment, there were statistically significant increases in lean body mass by 1.232 kg [0.181 +/- 0.004, 0.81 +/- 0.057, and 0.24 +/- 0.009 kg in the upper body (P = 0.021), trunk (P = 0.001), and lower body (P = 0.047), respectively]. In the E group, the increase was 0.31 +/- 0.004, 0.021 +/- 0.03, and 0.056 +/- 0.05 kg in the upper body, trunk, and lower body, respectively. In the E/A group, body fat was reduced by 0.90 kg (P = 0.18 for the trunk only), and percentage body fat declined by 7.4% (P < or = 0.05 for all body parts). Lower body strength increased by 23.1 kg (51 lb) in the E/A group vs. only 11 kg (24.25 lb) in the E group (P = 0.002 between groups). A statistically significant increase in weight (2.7 +/- 5.1 vs. 0.1 +/- 4.6 lb; P < 0.05) was observed in the E/A group compared with the E group. When subjects were given self-reporting questionnaires, more improvement was noted in sexual functioning and quality of life in the E/A group when compared with patients receiving E alone. There were no noteworthy side effects. In conclusion, E/A replacement therapy can improve body composition, lower-body muscle strength, quality of life, and sexual functioning in postmenopausal women.

The role of exercise in the prevention and treatment of wasting in acquired immune deficiency syndrome

Involuntary weight loss with lean tissue depletion is a serious and AIDS-defining complication of HIV infection. This article explores definitions of AIDS wasting syndrome (AWS), its etiology, methods of assessing body composition, and pharmacological treatments. Recent research literature on the role of exercise in the prevention and treatment of AWS is reviewed. Included are studies of the safety of exercise, the effects of exercise on the immune system, and the effects of exercise on weight gain and body composition as well as studies of exercise in combination with medications and other interventions. Implications for clinical practice are discussed.

Metabolic Syndromes Associated With HIV: Mitigating the Side Effects of Drug Therapy

HIV infection and highly active antiretroviral therapy (HAART) are associated with a variety of metabolic disorders such as AIDS wasting syndrome, cachexia, sarcopenia, metabolic dysregulation, lipodystrophy, abnormalities of serum lipids, and lactic acidosis. Adjunctive therapies (eg, diet, antilipid therapy), risk-factor modification (eg, smoking cessation, blood pressure control), aerobic exercise, and anabolic treatments can be used to mitigate the effects of HIV infection and the adverse effects of HAART, thereby improving long-term health in individuals infected with HIV.

HIV-associated wasting in the HAART era: guidelines for assessment, diagnosis, and treatment

Wasting (malnutrition) and lipodystrophy are the two major nutritional alterations in human immunodeficiency virus (HIV)-infected individuals. Both wasting and lipodystrophy may involve a decrease in body fat content, while wasting-but not lipodystrophy-also includes the loss of lean body mass. Lipodystrophy has made the identification of wasting increasingly more difficult. The diagnosis of wasting depends on a definition of the condition that takes into account sex and cultural differences, as well as measurements of body cell mass. Patient management involves a concurrent, comprehensive approach designed to restore lost body cell mass and weight. The authors make recommendations for defining, diagnosing, and treating HIV-associated wasting. Specific therapies include testosterone replacement, other anabolic steroids, and recombinant human growth hormone. Other adjunctive measures, such as progressive resistance exercise and cytokine modulation, may also be utilized. Expected outcomes from effective treatment include restored body cell mass, improvement in quality of life, and reduced rates of hospitalization. Future directions for research should address the need for optimal treatment strategies.