Malnutrition associated with HIV/AIDS. Part One: Definition and scope, epidemiology, and pathophysiology

Analysis of drug-drug interactions in patients with HIV and metabolic syndrome

BACKGROUND

People with HIV (PWH) are living longer directly related to benefits of highly effective antiretroviral therapy (ART). However, concurrent with improved longevity is the growing prevalence of metabolic comorbidities that drive morbidity and mortality among PWH. There is an increasing repertoire of treatment options for metabolic disorders. Thus, it is important for clinicians to understand the drug-drug interactions (DDIs) between ART and treatments for metabolic disorders.

AREAS COVERED

This review will discuss DDIs between contemporary ART and agents used to treat metabolic syndrome (diabetes, dyslipidemia, obesity and hypertension). Literature review of published and unpublished data from manuscripts, conference proceedings, regulatory submissions, and drug prescribing information were conducted from the following sources: PubMed, Google, and Google Scholar through January 2024.

EXPERT OPINION

People with HIV have a high prevalence of metabolic disorders. Most significant DDIs between ART and treatments for metabolic disorders are unidirectional with ART as perpetrators, rather than victims, such that careful selection of ART with low DDI propensity can address the concern. However, there are data gaps with DDI data for long-acting ART as well as newer oral and injectable medications for diabetes and weight loss. Nanotechnology-based drug delivery platforms hold promise to address some problematic DDIs.

Macronutrient supplementation for malnourished HIV-infected adults: a review of the evidence in resource-adequate and resource-constrained settings

Access to antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection has expanded rapidly throughout sub-Saharan Africa, but malnutrition and food insecurity have emerged as major barriers to the success of ART programs. Protein-calorie malnutrition (a common form of malnutrition in the region) hastens HIV disease progression, and food insecurity is a barrier to medication adherence. Analyses of patient outcomes have identified a low body mass index after the start of ART as an independent predictor of early mortality, but the causes of a low body mass index are multifactorial (eg, normal anthropometric variation, chronic inadequate food intake, and/or wasting associated with HIV infection and other infectious diseases). Although there is much information on population-level humanitarian food assistance, few data exist to measure the effectiveness of macronutrient supplementation or to identify individuals most likely to benefit. In this report, we review the current evidence supporting macronutrient supplementation for HIV-infected adults, we report on clinical trials in resource-adequate and resource-constrained settings, and we highlight priority areas for future research.

A pilot study of food supplementation to improve adherence to antiretroviral therapy among food-insecure adults in Lusaka, Zambia

BACKGROUND

The provision of food supplementation to food-insecure patients initiating antiretroviral therapy (ART) may improve adherence to medications.

METHODS

A home-based adherence support program at 8 government clinics assessed patients for food insecurity. Four clinics provided food supplementation, and 4 acted as controls. The analysis compared adherence (assessed by medication possession ratio), CD4, and weight gain outcomes among food-insecure patients enrolled at the food clinics with those enrolled at the control clinics.

RESULTS

Between May 1, 2004, and March 31, 2005, 636 food- insecure adults were enrolled. Food supplementation was associated with better adherence to therapy. Two hundred fifty-eight of 366 (70%) patients in the food group achieved a medication possession ratio of 95% or greater versus 79 of 166 (48%) among controls (relative risk = 1.5; 95% confidence interval: 1.2 to 1.8). This finding was unchanged after adjustment for sex, age, baseline CD4 count, baseline World Health Organization stage, and baseline hemoglobin. We did not observe a significant effect of food supplementation on weight gain or CD4 cell response.

CONCLUSIONS

This analysis suggests that providing food to food-insecure patients initiating ART is feasible and may improve adherence to medication. A large randomized study of the clinical benefits of food supplementation to ART patients is urgently needed to inform international policy.

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.

The nutritional status of asymptomatic HIV-infected Africans: directions for dietary intervention?

OBJECTIVE

To compare the relationships between food (nutrient) intakes and biochemical markers of nutritional status of asymptomatic HIV-infected with HIV-uninfected subjects, to gain more information on the appropriate diet for HIV-infected persons at an early stage of infection.

DESIGN

Cross-sectional population-based survey.

SETTING

North West Province, South Africa.

SUBJECTS

Two hundred and sixteen asymptomatic HIV-infected and 1550 HIV-uninfected men and women volunteers aged 15 years and older, recruited as 'apparently healthy' subjects from 37 randomly selected sites.

OUTCOME MEASURES

Food and nutrient intakes, measured with a validated food-frequency questionnaire, and nutritional status indicated by anthropometric and biochemical variables, measured by a standardised methodology.

RESULTS

The prevalence of HIV infection in the study population was 11.9%. The anthropometric indices and nutrient intakes of HIV-infected and uninfected subjects did not differ significantly, indicating that these 216 HIV-infected subjects were at an early stage of infection. Of the biochemical nutritional status variables, high-density lipoprotein cholesterol and total cholesterol, haemoglobin, albumin and triglycerides were significantly lower in infected subjects. They also had higher globulin and liver enzyme levels than uninfected subjects. In infected subjects, serum albumin correlated significantly with serum lipids, serum vitamin A, serum vitamin E, serum iron, total iron-binding capacity and haemoglobin. The significant positive correlations of the liver enzymes with serum lipids, albumin, vitamin A and iron, observed in HIV-uninfected subjects, disappeared in the infected subjects. Polyunsaturated fat intake showed significant positive correlations with the increased liver enzymes in infected subjects. A principal components analysis indicated that, in infected subjects, increased liver enzymes correlated with higher consumption of maize meal and lower consumption of meat and vegetables.

CONCLUSIONS AND RECOMMENDATIONS

This survey indicated that asymptomatic HIV-infected subjects who followed a diet rich in animal foods had smaller decreases in serum albumin, haemoglobin and lipid variables, and smaller increases in liver enzymes, than those who consumed a diet based on staple foods. This suggests that animal foods are associated with improved nutritional status in HIV-infected persons. These results should be confirmed with intervention studies before dietary recommendations for asymptomatic HIV-infected individuals can be made.

Treatment guidelines for HIV-associated wasting

Patients with acquired immunodeficiency syndrome (AIDS) often suffer from weight loss manifested by a loss of body cell mass (BCM). The causes of human immunodeficiency virus (HIV)-associated wasting may include anorexia, malabsorption, and a variety of altered metabolic states. Malabsorption and diarrhea may result from gastrointestinal tract opportunistic infections or from direct effects of HIV on the gastrointestinal tract. Infection with HIV may produce metabolic derangements that alter nutrient utilization, resulting in loss of BCM. Nutritional assessment of the patient with AIDS should include an evaluation of BCM and physical and psychosocial functioning. Antiretroviral therapy and eradication of opportunistic infections do not always reverse wasting. Treatment should include nutritional counseling. Total parenteral nutrition is sometimes of benefit, particularly in patients with damaged gastrointestinal tracts. Dronabinol and megestrol acetate may promote weight gain; however, dronabinol may have adverse effects, and most of the gain with megestrol acetate is in fat rather than BCM. If gonadal dysfunction is present, testosterone replacement therapy should be included in the treatment plan. Some studies suggest that oral anabolic steroids may improve muscle strength and body composition. In randomized, placebo-controlled trials, mammalian-derived human growth hormone (rhGH[m]) has produced sustained weight and BCM gains in AIDS patients. If a patient continues to lose BCM after the above factors have been addressed and corrected, a 12-week course of rhGH[m] is indicated. Halting the progression of HIV-associated wasting may improve survival, enhance physical and social functioning, and enrich quality of life.

HIV/AIDS and nutrition: a bibliometric analysis

Diet and nutrition are directly involved in patient care protocols that reflect a shift in the treatment of HIV/AIDS as a chronic disease, with an emphasis on quality of life and expanded life trajectory. Research concerning HIV/AIDS and nutrition is multidisciplinary, yielding study results that appear in a wide variety of scholarly journals. The purpose of this research was to employ bibliometric techniques to evaluate the body of literature specific to HIV/AIDS and nutrition as well as to determine content overlap among major bibliographic citation databases.

A team approach to the treatment of AIDS wasting

Despite the aggressive use of antiretroviral agents, AIDS wasting (AW) affects many persons infected with HIV. AW is characterized by a disproportionate loss of metabolically active tissue, specifically body cell mass--tissue involved with glucose oxidation, protein synthesis, and immune system function. AW correlates with poor quality of life and clinical outcomes. This condition requires a multidisciplinary team approach for effective management. Optimal maintenance of lean body mass and reversal of AW involves a combination of appropriate antiretroviral use, opportunistic infection prophylaxis, optimal nutrition, exercise, body composition monitoring, anabolic agents including growth hormone (rhGH[m]) and testosterone supplementation, mental health support, economic aid, and legal assistance. The team approach to treatment of AW requires the coordinated activity of nurses, dietitians, physicians, pharmacists, social workers, case managers, reimbursement personnel, caregiver(s), physical therapists, and the patient. This article, based on clinical experience treating AW, explains how the condition is managed using a multidisciplinary team approach.

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.

Quality of life and self-care management strategies of PLWAs with chronic diarrhea

A case control design was used to examine quality of life and self-care management strategies in persons living with AIDS (PLWAs) with chronic diarrhea. PLWAs without chronic diarrhea (n = 20) as compared to those with chronic diarrhea (n = 20) reported significantly higher general health perceptions (p = .028). In contrast, comparisons on symptom status scores revealed that PLWAs without chronic diarrhea reported greater fatigue (p = .05), greater psychological distress (p = .005), and greater gastrointestinal discomfort (p = .01). Although the intensity of chronic diarrhea was reported as moderate to severe by 85% of the sample, no single category of self-care management strategies was used by more than 65% of respondents. The number of categories of self-care management activities was significantly correlated with general health perceptions. The study findings support the need to test nursing interventions aimed at improving symptom management in chronic diarrhea and facilitating self-care behaviors including those focused on increasing adherence to prescribed therapeutic regimens.

HIV and combination therapy: meeting the challenge of a new era

With the advent of combination therapy in the treatment of human immunodeficiency virus (HIV) infection, there has been a vast reduction in the number of people admitted to AIDS units as inpatients, and a marked improvement in the quality of life for people infected with HIV. Combination therapy comprises the combined administration of various powerful antiviral drugs to prevent CD4 cell destruction and minimize the chance of a rapidly replicating virus becoming resistant. This article presents an overview of the basic elements of this therapy, discussing some of the challenges that are a corollary of this new era. In particular, the implications of an extended period of survival and wellness for a group of people previously thought to be the victims of a strictly acute condition are addressed. These implications relate to therapeutic, psychological, employment, social and sexual issues. Finally, the issues facing carers (both lay and professional) are discussed.