HIV Wasting

by Bill Valenti, MD

HIV wasting remains a serious side effect of HIV disease for many patients. In the past, we have used a narrow definition of wasting: greater than 10% loss of body weight. In 2000, a panel met to review wasting and developed a definition that is more relevant to HIV disease in the era of HAART. Their definition of HIV-associated wasting requires that the patient meet one or more of the following criteria:

" 10% unintentional weight loss over 12 months
" 7.5% unintentional weight loss over 6 months
" 5% body cell mass (BCM) loss within 6 months
" Body Mass Index (BMI) < 20 kg/m2
" In men: BCM < 35% body weight AND BMI < 27 kg/m2
" In women: BCM < 23% body weight AND BMI < 27 kg/m2

This definition accounts for gender differences and also focuses on the importance of looking at body compartments rather than merely looking at weight alone.

In terms of patient evaluation, the panel recommends a comprehensive approach. This includes body composition measurements in addition to the standard history and physical examination. Routine laboratory testing includes serum testosterone (free and total), serum albumin, and thyroid function tests in addition to the usual tests of CD4 count and viral load. A dietary assessment and psychosocial evaluation are also included. Recommended body composition measurements include ideal body weight, body cell mass by bioelectrical impedence analysis (BIA) and body mass index.

As a part of a wasting-focused history, the panel recommends asking the following questions:

" Have you noticed any weight loss?
" Has your appetite changed?
" Have you developed diarrhea?
" Are you feeling weaker and more fatigued than normal?
" Are you having trouble getting around to perform daily activities?

The guidelines also include suggested treatments and recommendations for a follow-up plan. Available treatments for wasting are shown below. While the treatment plan for each patient will be unique to that patient, the guidelines recommend posttreatment follow-up every 3 months as a minimum. This follow-up should include interval history and physical examination, serial body weights and body cell mass by BIA, monitoring of HAART, assessment of ongoing medical and psychiatric problems, ongoing follow-up with a dietitian, and measurement of total and free testosterone each year as a minimum and/or more often as clinically necessary, especially in patients receiving testosterone-replacement therapy.

Some strategies recommended in the guidelines for formulating the treatment plan include monitoring HAART for maximum control of viral load and immune competence, correcting immediate causes of HIV-related wasting, addressing psychosocial issues or life-associated situations, improving nutritional intake, and treating anorexia.

These guidelines provide a good outline for the approach to HIV wasting in the era of HAART. The discussion of diagnosis and treatment would be incomplete, however, without at least mentioning anticipated outcomes of this new approach. In addition to patient monitoring, some of the anticipated outcomes of this approach include replacing lost BCM and weight, improved physical capabilities and quality of life, improved physical appearance, improved survival, decreased frequency of opportunistic infections and related complications, and decreased hospitalizations.


Dr. Bill Valenti is the Founding Medical Director of the Community Health Network, a community-based medical clinic for HIV/AIDS in Rochester, NY, where he continues to see patients. He is also Clinical Associate Professor of Medicine at the University of Rochester School of Medicine. He has been involved in AIDS treatment, research, and policy since the early 1980s.


REFERENCE

Polsky B, Kotler D, Steinhart C. HIV-associated wasting in the HAART era: Guidelines for assessment, diagnosis, and treatment. Aids Patient Care and STDs. 2001;15:411423.

The complete text of the panels recommendations is available on-line for a fee at the publishers web site: http://www.liebertonline.com