HIV-ASSOCIATED WASTING

Your patients may experience HIV-associated wasting even when their HIV virus is well controlled on antiretroviral treatments1

HIV-associated wasting is a serious disease that affects many different patients, including those with undetectable viral loads and normal CD4 counts.1,2

HIV-ASSOCIATED WASTING

Your patients may experience HIV-associated wasting even when their HIV virus is well controlled on antiretroviral treatments1

HIV-associated wasting is a serious disease that affects many different patients, including those with undetectable viral loads and normal CD4 counts.1,2

Over time, as patients lose weight, physical endurance may be lost3-13

HIV-associated wasting is characterized by abnormalities in the way the body uses carbohydrates, fats, and proteins to meet energy and tissue-building needs. As patients lose weight unintentionally, they also lose lean body mass (LBM), which can be associated with a decline in strength and functional performance.

HIV-associated wasting can impact morbidity and mortality3,4,7

  • HIV-associated wasting has been associated with negative outcomes for patients
    • Increased mortality
    • Impaired functional status
    • Accelerated disease progression

A decrease in weight of ≥3% from baseline or ≥5% over a 6-month period was a significant predictor of mortality in patients. With a ≥10% loss of weight from baseline, the risk of mortality was almost 6 times greater.2

Serostim is not indicated to reduce viral load or increase CD4 counts and was not shown to do so in clinical trials.

HIV-associated wasting can be a concern across a range of patients1,2,8,14

  • Patients infected with HIV who have undetectable viral loads and normal CD4 counts
  • Patients who have had HIV for a long time
  • Patients on antiretroviral therapy who have or have had an acute infection
  • Patients who are newly diagnosed with HIV and currently on antiretroviral therapy

Many factors contribute to the pathophysiology of unintentional weight loss4,7,15

HIV-associated wasting is a diagnosis of exclusion. There are several factors associated with reduced caloric intake or altered metabolism that may be important in triggering unintentional weight loss in your patients living with HIV.

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  • Proinflammatory cytokines have numerous effects throughout the body, including inducing the acute-phase response (APR)
  • APR is part of the early-defense or innate immune system, which is triggered by stimuli such as trauma, infection, stress, neoplasia, and inflammation
  • In patients with HIV, APR becomes chronic, leading to the continuing breakdown of muscle, which can lead to unintentional weight loss
  • Even with a controlled HIV infection, a sustained inflammatory state may persist indefinitely
  • A sustained inflammatory state contributes to multimorbidity and mortality
  • Even in patients with undetectable viral loads, the gut-associated lymphoid tissue (GALT) can serve as a reservoir of the HIV virus
  • This stimulates chronic inflammation and immune activation
  • HIV alters the gut flora and can lead to long-term effects on epithelial barrier and T-cell function in the gut
  • Over time, integrity of protective mucosal barrier is diminished
  • Disruptions are associated with inflammation and malabsorption of vital nutrients
  • Dysregulation of cellular pathways can lead to weight loss, inappropriate depletion of LBM, and preservation of body fat
  • A number of factors may promote excessive catabolic activity
    • Proinflammatory cytokines
    • Hormonal imbalances
    • Elevated resting energy expenditure
    • Stress
    • Increased cortisol levels
  • Changes affecting other cellular pathways, such as the phosphoinositide-3-kinase (PI3K) pathway, may also contribute to HIV-associated wasting
  • Characterized by disruption of the hormonal regulatory axes and abnormal levels of hormones, such as
    • Glucagon
    • Insulin
    • Epinephrine
    • Glucocorticoids, such as cortisol
  • These hormones regulate metabolism of proteins, lipids, and carbohydrates
  • Reduced serum IGF-1 levels may lead to increased protein degradation and loss of LBM
  • Shift in endocrine function towards increased levels of the catabolic hormone cortisol may contribute to wasting
  • Acquired GH resistance may result in decreased production of IGF-1 by the liver
  • Disruptions in the GH/IGF-1 axis can lead to elevated serum GH levels and reduced serum IGF-1 levels
  • Other factors may contribute to HIV-associated wasting
    • Diarrhea
    • Infections
    • Low testosterone

Asking your patients the right questions about their symptoms may help you identify the condition and intervene early

Ask your patients:

  • Do you have a loss of energy?
  • Do you frequently feel tired during daily activities, such as walking up stairs?
  • Are any activities more difficult to perform?
  • Do you need to rest more often?
  • Are you exercising less?
  • Have you had unintentional weight loss?
  • Have you recently lost weight without trying?
  • Do any changes in your weight negatively affect your health and how you feel?
  • Do your clothes fit more loosely than normal due to unintentional weight loss?
  • Have friends, family, or coworkers noticed any changes in the way that you look based on changes in your weight?
  • Consider measuring weight, calculating BMI, and reviewing a weight history of your patient to help screen for HIV-associated wasting.

For additional guidance on speaking with your patients about this condition, download the Physician-Patient Dialogue Guide.
DOWNLOAD DIALOGUE GUIDE

Show References

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  1. Wasserman P, Segal-Maurer S, Wehbeh W, Rubin DS. Wasting disease, chronic immune activation, and inflammation in the HIV-infected patient. Top Clin Nutr. 2011;26(1):14-28.
  2. Mangili A, Murman DH, Zampini AM, Wanke CA. Nutrition and HIV infection: review of weight loss and wasting in the era of highly active antiretroviral therapy from the nutrition in healthy living cohort. Clin Infec Dis. 2006;42(6):836-842.
  3. Dudgeon WD, Phillips KD, Carson JA, Brewer JA, Durstine JL, Hand GA. Counteracting muscle wasting in HIV-infected individuals. HIV Med. 2006;7(5):299-310.
  4. Gelato M, McNurlan M, Freedland E. Role of recombinant human growth hormone and HIV-associated wasting and cachexia: pathophysiology and rationale for treatment. Clin Ther. 2007;29(11):2269-2288.
  5. Singh K. The role of physiotherapy in AIDS wasting syndrome. Int J Lat Res Sci Tech. 2012;1(1):85-88.
  6. Macallan DC, Noble C, Baldwin C, et al. Energy expenditure and wasting in human immunodeficiency virus infection. N Engl J Med. 1995;333(2):83-88.
  7. Grinspoon S, Mulligan K; for the Department of Health and Human Services Working Group on the Prevention and Treatment of Wasting and Weight Loss. Weight loss and wasting in patients infected with human immunodeficiency virus. Clin Infec Dis. 2003;36(Suppl 2):S69-S78.
  8. Roubenoff R, Grinspoon S, Skolnik PR, et al. Role of cytokines and testosterone in regulating lean body mass and resting energy expenditure in HIV-infected men. Am J Physiol Endocrinol Metab. 2002;283(1):E138-E145.
  9. Perry CM, Wagstaff AJ. Recombinant mammalian cell-derived somatropin. A review of its pharmacological properties and therapeutic potential in the management of wasting associated with HIV infection. Biodrugs. 1997;8(5):394-414.
  10. Grace JM, Semple SJ, Combrink S. Exercise therapy for human immunodeficiency virus/AIDS patients: guidelines for clinical exercise therapists. J Exer Sci Fit. 2015;13(1):49-56.
  11. Crotty B, Mcdonald J, Mijch AM, Smallwood RA. Percutaneous endoscopic gastronomy feeding in AIDS. J Gastroenterol Hepatol. 1998;13:371-375.
  12. Keithley JK, Dulay AMS, Swanson B, Zeller JM. HIV infection and obesity: a review of the evidence. JANAC. 2009;20(4):260-274.
  13. Wilson D, Hurtado RM, Digumarthy S. Case 18-2009: a 24-year-old woman with AIDS and tuberculosis with progressive cough, dyspnea, and wasting. N Engl J Med. 2009;360:2456-2464.
  14. Ashby J, Goldmeier D, Sadeghi-Nejad H. Hypogonadism in human immunodeficiency virus-positive men. Korean J Urol. 2014;55:9-16.
  15. Mankal PK, Kotler DP. From wasting to obesity, changes in nutritional concerns in HIV/AIDS. Encrinol Metab Clin N Am. 2014;43:647-663.
  16. Cray C, Zaias J, Altman NH. Acute phase response in animals: a review. Comp Med. 2009;59(6):517-526.
  17. Deeks SG, Russell T, Douek DC. Systemic effects of inflammation on health during chronic HIV infection. Immunity. 2013;39(4):633-645.
  18. Castaneda C. Muscle wasting and protein metabolism. J Anim Sci. 2002;80(suppl 2):E98-E105.
  19. Koethe J, Heimburger D, PrayGod G, Filteau S. From wasting to obesity: the contribution of nutritional status to immune activation in HIV infection. Journal of Infectious Diseases. 2016;214(S2):S75-82.
  20. Dandekar S. Pathogenesis of HIV in the gastrointestinal tract. Current HIV/AIDS Reports. 2007;4:10-15.
  21. de Pee S, Semba RD. Role of nutrition in HIV infection: review of evidence for more effective programming in resource-limited settings. Food Nutr Bull. 2010;31(4):S313-S344.
  22. Corcoran CP, Grinspoon S. Diagnosis and treatment of endocrine disorders in the HIV-infected patient. The Body. www.thebody.com/content/art12325.html. Accessed August 30, 2018.
  23. Falutz J. Growth hormone and HIV infection: contribution to disease manifestations and clinical implications. Best Pract Res Cl En. 2011;25:517-529. 1998. Accessed August 30, 2018.