Wasting syndrome: nutritional support in HIV infection

Predictors of recovery rate among undernourished HIV-positive adults treated with ready-to-use therapeutic food at Debre Markos Comprehensive Specialized Hospital: A retrospective cohort study

BACKGROUND

Nutritional support is becoming more widely acknowledged as a crucial component of the key package of care for HIV/AIDS patients. This nutritional support is exceptionally important for patients in sub-Saharan Africa, including Ethiopia, where HIV/AIDS is very prevalent. However, there is a lack of evidence on the recovery rate and predictors at the study site and at large in Ethiopia. Therefore, this study will give some insight into the recovery rate and its predictors among under-nourished HIV-positive adults treated with Ready to Use Therapeutic Food (RUTF) attending at Debre Markos referral hospital. Moreover, the findings of this study will be used by both governmental and non-governmental organizations to allocate more resources to mitigate the nutritional problems for people living with HIV.

METHODS

An institution-based retrospective cohort study was conducted among 453 under-nourished HIV positive adults treated with RUTF at Debre Markos referral Hospital from the 1st of July, 2015 to the 31st of December, 2017. The study participants were selected using a simple random sampling technique. Data were extracted from patient charts using a standardized data extraction checklist. Data were entered into Epi-Data Version 4.2 and analyzed using Stata Version 14. The Kaplan-Meier survival curve was used to estimate the time to recovery. Log-rank test was used to compare the recovery time between different baseline categorical variables. The bivariable and multivariable Cox-proportional hazard regression models were fitted for potential predictors of recovery time. Adjusted hazard Ratios (AHRs) with 95% CIs were used to measure the strength of association and test statistical significance.

RESULTS

A total of 453 undernourished HIV-positive adults were included in the final analysis. About 201, 44.4% (95%CI: 38.9, 49.0%) patients participating in the RUTF program were recovered based on predetermined exit criteria with incidence of 10.65 (95% CI: 9.28, 12.23) per 100 person-month observations. Being moderately undernourished (AHR: 11.0, 95% CI: 5.3, 23.1), WHO clinical stage (I or II) (AHR:1.8, 95% CI: 1.2, 2.6), and working functional status at baseline (AHR = 2.34, 95%CI: 1.01,5.45) were predictors of recovery time.

CONCLUSION

This study concluded that the overall nutritional recovery rate was below the acceptable minimum requirement which at least 75% of patients should recovered. Mild to moderate undernutrition at baseline, WHO clinical stage I or II at enrolment, and working functional status were found to be predictors of recovery time in HIV/AIDS patients treated with the RUTF. As a result, special attention should be paid to severely malnourished patients, WHO clinical stages III or higher, and patients who are bedridden or ambulatory during treatment.

Randomized controlled trial of a community-based intervention on HIV and nutritional outcomes at 6 months among women living with HIV/AIDS in rural India

OBJECTIVE

To assess the impact of nurse-led Asha (Accredited Social Health Activist)-support behavioral and nutritional intervention among women living with HIV/AIDS (WLH/A) in rural India.

DESIGN

Cluster randomized controlled trial.

METHODS

Sixteen Primary Health Centers serving WLH/A in Andhra Pradesh were grouped into four regional clusters that were randomly allocated into one of four arms. All four groups included Asha-support and consisted of: Asha-support only (control group); nutrition education; nutrition supplementation; and the combination of supplementation and education. Differences between baseline and 6-month follow-up for key physiological outcomes (BMI, CD4 cell count) were analyzed using factorial mixed models that accounted for geographic clustering.

RESULTS

At 6 months, all groups improved CD4 cell count: Asha only [mean difference score (D) = 343.97, standard deviation (SD) = 106.94], nutrition education (D = 356.15, SD = 0.69), nutrition supplement (D = 469.66, SD = 116.0), and nutrition supplement and education (D = 530.82, SD = 128.56). In multivariable models, Asha-support and nutrition, and Asha-support and nutrition supplement interventions demonstrated independent significant improvements in CD4 cell count; the interaction term was significant [estimate = 529.9; 95% confidence interval (CI) 512.0, 547.8; P = 0.006]. BMI also increased for all groups: Asha only (D = 0.95, SD = 0.82), Asha and nutrition education (D = 1.28, SD = 0.53), Asha and nutrition supplement (D = 2.38, SD = 0.60), nutrition supplement, and nutrition supplement and education (D = 2.72, SD = 0.84). Nutrition supplementation and nutrition education demonstrated independent effects on BMI; the interaction term was not significant (estimate = 0.27; 95% CI = 2.5, 2.7; P = 0.80).

CONCLUSION

Interventions supported by community workers were efficacious at improving physiological outcomes and may be beneficial at meeting critical healthcare needs of vulnerable WLH/A in India.

Effect of probiotic bacteria on microbial host defense, growth, and immune function in human immunodeficiency virus type-1 infection

The hypothesis that probiotic administration protects the gut surface and could delay progression of Human Immunodeficiency Virus type1 (HIV-1) infection to the Acquired Immunodeficiency Syndrome (AIDS) was proposed in 1995. Over the last five years, new studies have clarified the significance of HIV-1 infection of the gut associated lymphoid tissue (GALT) for subsequent alterations in the microflora and breakdown of the gut mucosal barrier leading to pathogenesis and development of AIDS. Current studies show that loss of gut CD4+ Th17 cells, which differentiate in response to normal microflora, occurs early in HIV-1 disease. Microbial translocation and suppression of the T regulatory (Treg) cell response is associated with chronic immune activation and inflammation. Combinations of probiotic bacteria which upregulate Treg activation have shown promise in suppressing pro inflammatory immune response in models of autoimmunity including inflammatory bowel disease and provide a rationale for use of probiotics in HIV-1/AIDS. Disturbance of the microbiota early in HIV-1 infection leads to greater dominance of potential pathogens, reducing levels of bifidobacteria and lactobacillus species and increasing mucosal inflammation. The interaction of chronic or recurrent infections, and immune activation contributes to nutritional deficiencies that have lasting consequences especially in the HIV-1 infected child. While effective anti-retroviral therapy (ART) has enhanced survival, wasting is still an independent predictor of survival and a major presenting symptom. Congenital exposure to HIV-1 is a risk factor for growth delay in both infected and non-infected infants. Nutritional intervention after 6 months of age appears to be largely ineffective. A meta analysis of randomized, controlled clinical trials of infant formulae supplemented with Bifidobacterium lactis showed that weight gain was significantly greater in infants who received B. lactis compared to formula alone. Pilot studies have shown that probiotic bacteria given as a supplement have improved growth and protected against loss of CD4+ T cells. The recognition that normal bacterial flora prime neonatal immune response and that abnormal flora have a profound impact on metabolism has generated insight into potential mechanisms of gut dysfunction in many settings including HIV-1 infection. As discussed here, current and emerging studies support the concept that probiotic bacteria can provide specific benefit in HIV-1 infection. Probiotic bacteria have proven active against bacterial vaginosis in HIV-1 positive women and have enhanced growth in infants with congenital HIV-1 infection. Probiotic bacteria may stabilize CD4+ T cell numbers in HIV-1 infected children and are likely to have protective effects against inflammation and chronic immune activation of the gastrointestinal immune system.

Nutrition outcomes of HIV-infected malnourished adults treated with ready-to-use therapeutic food in sub-Saharan Africa: a longitudinal study

BACKGROUND

Among people living with HIV/AIDS, nutritional support is increasingly recognized as a critical part of the essential package of care, especially for patients in sub-Saharan Africa. The objectives of the study were to evaluate the outcomes of HIV-positive malnourished adults treated with ready-to-use therapeutic food and to identify factors associated with nutrition programme failure.

METHODS

We present results from a retrospective cohort analysis of patients aged 15 years or older with a body mass index of less than 17 kg/m² enrolled in three HIV/AIDS care programmes in Africa between March 2006 and August 2008. Factors associated with nutrition programme failure (patients discharged uncured after six or more months of nutritional care, defaulting from nutritional care, remaining in nutritional care for six or more months, or dead) were investigated using multiple logistic regression.

RESULTS

Overall, 1340 of 8685 (15.4%) HIV-positive adults were enrolled in the nutrition programme. At admission, median body mass index was 15.8 kg/m² (IQR 14.9-16.4) and 12% received combination antiretroviral therapy (ART). After a median of four months of follow up (IQR 2.2-6.1), 524 of 1106 (47.4%) patients were considered cured. An overall total of 531 of 1106 (48.0%) patients failed nutrition therapy, 132 (11.9%) of whom died and 250 (22.6%) defaulted from care. Men (OR = 1.5, 95% CI 1.2-2.0), patients with severe malnutrition at nutrition programme enrolment (OR = 2.2, 95% CI 1.7-2.8), and those never started on ART (OR = 4.5, 95% CI 2.7-7.7 for those eligible; OR = 1.6, 95% CI 1.0-2.5 for those ineligible for ART at enrolment) were at increased risk of nutrition programme failure. Diagnosed tuberculosis at nutrition programme admission or during follow up, and presence of diarrhoeal disease or extensive candidiasis at admission, were unrelated to nutrition programme failure.

CONCLUSIONS

Concomitant administration of ART and ready-to-use therapeutic food increases the chances of nutritional recovery in these high-risk patients. While adequate nutrition is necessary to treat malnourished HIV patients, development of improved strategies for the management of severely malnourished patients with HIV/AIDS are urgently needed.

Acceptability and effectiveness of chickpea sesame-based ready-to-use therapeutic food in malnourished HIV-positive adults

OBJECTIVE

A prospective descriptive study to assess acceptability and effectiveness of a locally made ready-to-use therapeutic food (RUTF) in HIV-infected chronically sick adults (CSA) with mid-upper-arm circumference (MUAC) <210 mm or pitting edema.

METHODS

Sixty-three wasted AIDS adults were prescribed 500 g representing ~2600 kcal/day of locally made RUTF for three months and routine cotrimoxazole. Weight, height, MUAC, Karnofsky score and morbidity were measured at admission and at monthly intervals. The amount of RUTF intake and acceptability were assessed monthly.

RESULTS

Ninety-five percent (60/63) of the CSA that were invited to join the study agreed to participate. Mean daily intake in these 60 patients was 300 g/person/day (~1590 Kcal and 40 g of protein). Overall, 73.3% (44/60) gained weight, BMI, and MUAC. The median weight, MUAC and BMI gains after three months were 3.0 kg, 25.4 mm, and 1.1 kg/m(2), respectively. The intervention improved the physical activity performance of participants and 78.3% (47/60) regained sufficient strength to walk to the nearest health facility. Mortality at three months was 18.3% (11/60).

CONCLUSION

Locally made RUTF was acceptable to patients and was associated with a rapid weight gain and physical activity performance. The intervention is likely to be more cost effective than nutritional support using usual food-aid commodities.

Illuminating the interrelated immune and endocrine adaptations after multiple exposures to short immobilization stress by in vivo blocking of IL-6

Intermittent psychological stress was induced in adult rats by 2 h/day of immobilization stress for 4 days, with or without blocking the function of IL-6 by using an anti-IL-6 antibody. Basal concentrations of serum corticosterone, IL-1β, IL-6, and TNF-α were assessed 24 h after the last intervention, as were levels of glucocorticoid receptors (GR) and activities of glucocorticoid-inducible enzymes (tyrosine aminotransferase and glutamine synthetase) in muscle and liver. Whole blood cultures were used to assess both spontaneous and LPS-induced reactivity of peripheral blood mononuclear cells. Stress increased corticosterone concentration in a manner partially modulated by IL-6. Serum IL-1β concentration was downregulated during stress when IL-6 was blocked ( P < 0.01). LPS-induced IL-6 secretion by peripheral blood mononuclear cells in vitro correlated positively with serum IL-1β concentration in antibody-treated groups, independently of stress ( R = 0.70 in nonstressed and R = 0.78 in stressed rats; both P < 0.05), whereas serum corticosterone concentration correlated positively with LPS-induced secretion of IL-6 only in control rats ( R = 0.66; P < 0.05). Reductions in liver GR levels indicated independent effects of stress (34.5%) and anti-IL-6 antibody (16.7%) and additive effects for both (62.5%). Similar results are reported for vastus muscle. Conversely, stress increased tyrosine aminotransferase and glutamine synthetase activities in muscle and liver with a significant ( P < 0.05) effect of anti-IL-6 antibody only seen in stressed livers. In conclusion, IL-6 plays a role in maintaining circulating IL-1β concentration after multiple exposures to stress, thus promoting a continued elevation of corticosterone release; in peripheral tissues, IL-6 antagonizes the effects of glucocorticoids, especially at the level of GR concentration.

Human aflatoxicosis in developing countries: a review of toxicology, exposure, potential health consequences, and interventions

Aflatoxins are well recognized as a cause of liver cancer, but they have additional important toxic effects. In farm and laboratory animals, chronic exposure to aflatoxins compromises immunity and interferes with protein metabolism and multiple micronutrients that are critical to health. These effects have not been widely studied in humans, but the available information indicates that at least some of the effects observed in animals also occur in humans. The prevalence and level of human exposure to aflatoxins on a global scale have been reviewed, and the resulting conclusion was that approximately 4.5 billion persons living in developing countries are chronically exposed to largely uncontrolled amounts of the toxin. A limited amount of information shows that, at least in those locations where it has been studied, the existing aflatoxin exposure results in changes in nutrition and immunity. The aflatoxin exposure and the toxic affects of aflatoxins on immunity and nutrition combine to negatively affect health factors (including HIV infection) that account for >40% of the burden of disease in developing countries where a short lifespan is prevalent. Food systems and economics render developed-country approaches to the management of aflatoxins impractical in developing-country settings, but the strategy of using food additives to protect farm animals from the toxin may also provide effective and economical new approaches to protecting human populations.

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.

Assessment of nutritional status, body composition, and human immunodeficiency virus-associated morphologic changes

Nutritional status should be assessed at regular intervals as part of management of human immunodeficiency virus (HIV) infection. The simplest approach to assessment is serial weight measurement. A comprehensive nutritional assessment includes (1) anthropometric measurements of body composition; (2) biochemical measurements of serum protein, micronutrients, and metabolic parameters; (3) clinical assessment of altered nutritional requirements and social or psychological issues that may preclude adequate intake; and (4) measurement of dietary intake. Techniques for measuring body composition of fat and lean body mass include anthropometry and bioelectric impedance analysis. Other techniques, including dual X-ray absorptiometry (DXA), hydrodensitometry, total body potassium measurement, and cross-sectional computed tomography or magnetic resonance imaging are available in research centers. Anthropometry, including waist-hip ratios, regional DXA, and cross-sectional imaging, is best for detecting morphologic changes associated with fat redistribution syndrome. Nutritional assessment and intervention in children with HIV can help to prevent stunted growth and development.

The role of nutrition in pediatric HIV/AIDS: a review of micronutrient research

It is becoming increasingly evident that nutrition is not only an important component of health but also that levels of specific nutrients can affect disease expression. This is particularly apparent in the realm of HIV disease. Despite this knowledge, research in this area, especially pertaining to the pediatric population, has been limited. This report presents a narrative review and critique of the work that has been conducted in the area of micronutrients including descriptive, correlational, and intervention studies. Gaps in knowledge, recommendations for future research, and nursing implications are highlighted. Current information suggests a role for micronutrients in the treatment of HIV disease, and further research will help develop these adjunct therapies that can affect the overall outcomes and quality of life of these patients.

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.

Palliative care and AIDS: 2 – Gastrointestinal symptoms

With the use of more intensive antiretroviral therapies (highly-active antiretroviral therapy, HAART) particularly in first world countries, reductions in the mortality and morbidity of HIV infection are being seen. However, though the prevalence of symptoms may change, symptom control does continue to be a problem for many people with HIV, particularly as their disease progresses. This is the second of 2 CME articles about palliative care and HIV infection. The first gave a background to palliative care, and covered symptom control of pain1. This article gives suggestions for the treatment of common gastrointestinal symptoms in HIV infection; nausea and vomiting, cachexia and anorexia and chronic diarrhoea.

Predictors of HIV infection among newly sentenced male prisoners

The prevalence of individuals with or at risk for HIV infection in prisons and jails is severalfold higher than age-adjusted rates in surrounding communities. This HIV serosurvey of 975 newly sentenced male prisoners employed a new methodology that anonymously linked individual information to HIV serologic data. The HIV prevalence was 6.1%; multivariate regression analysis indicated injection drug use (OR = 18.9), black race (OR = 5.5), Hispanic ethnicity (OR = 3.4), psychiatric illness (OR = 3.1) and a history of having had a sexually transmitted disease (OR = 2.2) were independent predictors of HIV infection. Laboratory markers such as hypoalbuminemia, an elevated aspartate aminotransferase (AST) level, leukopenia, anemia, and thrombocytopenia suggest increased risk for HIV among prisoners, particularly in settings where HIV testing resources are scarce. This study, unlike those reported in other geographic regions, indicated that the majority (71%) of HIV-seropositive persons self-reported their HIV status. This finding may suggest that HIV-infected individuals will self-report their status if HIV care is comprehensive and consistent. The large number of HIV-infected individuals within prisons makes prisons important sites for the introduction of comprehensive HIV-related care. This is particularly relevant in that development of new guidelines issued for the management of HIV infection in which potent combination antiretroviral therapy has been demonstrated to decrease morbidity and mortality. The high prevalence of HIV-seronegative inmates with self-reported high-risk behaviors also suggests the importance of prisons as sites for the introduction of appropriate risk-reduction interventions.

Comparison of total parenteral nutrition and an oral, semielemental diet on body composition, physical function, and nutrition-related costs in patients with malabsorption due to acquired immunodeficiency syndrome

BACKGROUND

The nutrition management of patients with malabsorption syndromes due to acquired immunodeficiency syndrome (AIDS) is problematic. The aim of this study was to compare the effects of total parenteral nutrition (TPN) and an oral, semielemental diet (SED) on body weight, body composition, quality of life, survival, and medical costs in AIDS patients with malabsorption.

METHODS

This was a prospective, randomized, open-label study performed in outpatients. Twenty-three AIDS subjects (TPN group, 12; SED group, 11) with cryptosporidiosis, microsporidiosis, or malabsorption of unknown cause were randomized and followed. Subjects were prescribed equivalent amounts of formulas of similar composition for 3 months. Monthly estimations of caloric intake, body weight, body composition by bioimpedance analysis, and quality of life were recorded. Nutritional variables were analyzed by repeated-measures analysis of covariance, with the baseline measure as the covariate. Nutrition-related medical costs, survival, and indices of absorptive and immune function were compared,

RESULTS

Subjects had lost an average of 1.5 and 1.0 kg body wt/mo for TPN and SED during the 6 months before study entry (p < not significant). The TPN group consumed more total calories than the SED group (p < .05). Weight change during therapy was significantly different from pretreatment in both groups (p < .01 for TPN, p = .023 for SED). The TPN group gained more weight than the SED group (p = .057) and significantly more fat (p = .02), but the changes in body cell mass were similar in the two groups. Changes in weight and body composition correlated with caloric intake but not the mode of feeding. The SED group scored significantly better than the TPN group on a physical functioning subscale of quality of life (p < .01). Survival was similar in the two groups. TPN therapy cost almost four times more than SED. Peripheral blood CD4+ lymphocyte numbers were unaffected by either therapy. Intestinal function was not affected by either therapy.

CONCLUSIONS

An oral SED may reverse weight loss and wasting in AIDS patients with malabsorption.

Abuse potential of dronabinol (Marinol)

Dronabinol is an oral form of delta-9-tetrahydrocannabinol indicated for treatment of anorexia associated with weight loss in individuals with AIDS, and nausea and vomiting associated with cancer chemotherapy. The authors reviewed the literature and conducted surveys and interviews among addiction medicine specialists, oncologists, researchers in cancer and HIV treatment, and law enforcement personnel to determine the abuse liability of dronabinol. There is no evidence of abuse or diversion of dronabinol. Available prescription tracking data indicates that use remains within the therapeutic dosage range over time. Healthcare professionals have detected no indication of "scrip-chasing" or "doctor-shopping" among the patients for whom they have prescribed dronabinol. Cannabis-dependent populations, such as those treated in our Clinic and seen by the addiction medicine specialists we interviewed, have demonstrated no interest in abuse of dronabinol. There is no street market for dronabinol, and no evidence of any diversion of dronabinol for sale as a street drug. Furthermore, dronabinol does not provide effects that are considered desirable in a drug of abuse. The onset of action is slow and gradual, it is at most only weakly reinforcing, and the overwhelming majority of reports of users indicate that its effects are dysphoric and unappealing. This profile of effects gives dronabinol a very low abuse potential.

Therapeutic options for HIV-associated bodyweight loss. A risk-benefit analysis

Involuntary bodyweight loss, a common complication of infection with HIV, is an indicator of poor prognosis and decreased survival. Because of the multifactorial pathogenesis of HIV-related wasting, emerging therapies are directed at the multiple proposed mechanisms of involuntary bodyweight loss. The initial evaluation and treatment of HIV-related bodyweight loss is focused on the identification and treatment of reversible causes of bodyweight loss, such as secondary opportunistic infections or endocrine dysfunction. Nutritional intervention should begin in the early stages of HIV infection and continue throughout the life of the patient. Of the appetite stimulants, megestrol most consistently promotes bodyweight gain, but with a predominance of fat, not lean, body mass. Anabolic therapies such as testosterone derivatives and recombinant human growth hormone (somatropin) stimulate the addition of lean body mass and are begin actively researched for the treatment of HIV-associated wasting. Finally, thalidomide, a potent inhibitor of tumour necrosis factor-alpha, is a potentially useful therapy that is still under investigation. New research into the treatment of HIV-related bodyweight loss is focusing on combination therapies.

HIV and medical nutrition therapy

In those who are infected with human immunodeficiency virus, poor nutritional status can result from numerous causes, including anorexia, catabolism, chronic infection, fever, poor nutrient intake, nausea, vomiting, diarrhea, malabsorption, metabolic disturbances, lack of access to food, depression, and side effects of drug, radiation, and chemotherapy treatments. A compromised immune system may not be reversed by any medical treatments at this time, but malnutrition may be prevented and reversed by using current therapies, including medical nutrition therapy that includes nutrition assessment, the development of an individualized nutrition therapy plan, and implementation of the therapy. There is substantial evidence that medical nutrition therapy saves lives, reduces morbidity, improves health outcomes, reduces costs, and shortens hospital stays.

N-acetylation among HIV-positive patients and patients with AIDS: when is fast, fast and slow, slow?

BACKGROUND

The discrepancy between genotype and expressed phenotype of the polymorphic N-acetyltransferase (NAT2) has been suggested by separate genotypic and phenotypic studies in populations with human immunodeficiency virus (HIV). Only one study has examined both genotype and phenotype in the same population, and no discrepancies were observed.

METHODS

In a cross-sectional study, 105 HIV-positive patients and patients with acquired immunodeficiency syndrome (AIDS) were phenotyped for NAT2 activity with use of caffeine as an in vivo probe; 50 of these patients were also genotyped by restriction mapping and allele-specific amplification. In a longitudinal study, 23 patients were phenotyped at least twice during the 2-year study.

RESULTS

The distribution of the NAT2 phenotype among the 105 patients was unimodal and skewed toward slow acetylators as opposed to the bimodal distribution observed in healthy white populations. The genotype distribution was 26:24 slow:fast. There were 18 discrepancies between genotype and phenotype: 12 slow acetylators with fast genotypes and six fast acetylators with slow genotypes. No drug-related effects on NAT2 activity were apparent, but the role of disease progression was evident. Among the slow acetylators whose genotype was fast, the incidence of AIDS was higher (six of 12) than that among the fast acetylators whose genotype was fast (two of 14). Among patients phenotyped more than once (mean time between samples, 10.4 months) changes in phenotype from fast to slow were associated with progression of HIV infection.

CONCLUSIONS

Disease progression in HIV infection and AIDS may alter expression of the NAT2 gene. The genotype and the phenotype are not interchangeable measurements. In the HIV population, to know the genotype is useful only if the phenotype is also known and vice versa.

Decreased fat and nitrogen losses in patients with AIDS receiving medium-chain-triglyceride-enriched formula vs those receiving long-chain-triglyceride-containing formula

OBJECTIVE

The purpose of this study was to compare two enteral formulas, differing only in fat source, for product acceptance, tolerance, and effect on fat malabsorption and nutritional status in subjects with acquired immune deficiency syndrome (AIDS).

DESIGN

The double-blind, randomized 15-day trial was divided into a 3-day period in which solid food was consumed followed by a 12-day experimental period in which liquid formulas were consumed.

SETTING/SUBJECTS

Twenty-three men and one woman with AIDS and fat malabsorption completed the study. The study was conducted in the General Clinical Research Center, University of Alabama Hospital, University of Alabama at Birmingham. Laboratory assays were performed in the Department of Nutrition Sciences.

INTERVENTIONS

After 3 days of consuming a controlled, solid food diet containing 100 g fat per day from mixed sources to document fat malabsorption, subjects were randomly assigned to one of two groups. Each group received a liquid formula containing 35% of energy as fat for 12 days. One group received a formula containing 85% medium-chain triglycerides (MCTs) and the control group received a formula containing 100% long-chain triglycerides.

MAIN OUTCOME MEASURES

Determinations included stool number, consistency, weight, and fat and nitrogen content; urine nitrogen and creatinine levels; and body weight.

STATISTICAL ANALYSIS PERFORMED

Subject demographic and other baseline characteristics were compared using two-sample t tests; stool and urine assessments were compared between groups at the initial experimental period using two-sample t tests; changes from initial to final experimental periods were assessed by means of analysis of covariance; changes in pooled intake, body weight, and the number and consistency of bowel movements were also assessed using analysis of covariance. All statistical tests were two-tailed and considered significant at P < .05.

RESULTS

Within-group comparisons indicated that subjects fed the MCT formula showed significantly decreased stool fat and stool nitrogen content (P = .01 and P = .03, respectively) and increased fat absorption (P = .03), whereas those fed the control formula did not. Differences in stool fat between the groups were not statistically significant. However, the difference in fat absorption from the initial to final formula period was significant (P = .04). Subjects consuming the MCT formula also tended to have a decreased number of bowel movements and abdominal symptoms, whereas subjects fed the control formula showed no improvement. All subjects maintained their body weights.

APPLICATIONS

There may be advantages to using an MCT-based formula in the treatment of AIDS-associated malabsorption.

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

A documented association exists between nutritional status and immunologic function, development, and outcome of infectious processes, and treatment-related toxicity and vital organ function. In persons with AIDS, nutritional deficits precipitate a cycle that results in a downward spiral of weight lost, malabsorption, diarrhea, anorexia, body image disturbance, and increased risk for morbidity and mortality. This article presents an overview of the malnutrition in HIV/AIDS patients. It critiques the current Centers for Disease Control's definitions of wasting syndrome, describes the incidence of weight loss, delineates the implications of untreated malnutrition, and traces the etiology of weight loss and contributing factors. This article serves as an introduction to HIV/AIDS related malnutrition. A subsequent article will review nursing implications and clinical management programs.

Complementary and alternative medicine and HIV/AIDS. Part II: Selected literature review

People with HIV/AIDS are using complementary and alternative medicine (CAM) to improve general health, prevent opportunistic infections, treat symptoms, and reduce side effects from biomedical treatments. This paper reviews the research and narrative literature on CAM use in people with HIV/AIDS and covers (1) nutrition; (2) exercise; (3) traditional and ethno-medicine; (4) miscellaneous products; and (5) psychosocial interventions.

A review of mechanisms of wasting in HIV disease

According to estimates, between 50% to 90% of patients infected with the Human Immunodeficiency Virus (HIV) will experience some form of malnutrition. The degree and types of malnutrition are attributed to alterations in nutrient intake, absorption, and metabolism. Causes for each of these changes are complex and multifactorial. Research on treatment modalities generally concentrates on a single mechanism and reports varying degrees of short-term benefit. Appetite stimulation along with special diets, oral supplements, and nonvolitional enteral or parenteral nutrient provision may improve nutrient intake and body weight. Therapies aimed at the rehabilitation and improvement of the pool of functioning protein stores, such as alteration of inflammatory response, restoration of hormonal balance, and exercise are under investigation. Longer term studies will allow researchers to observe effects of therapies on overall body functions. With the development of clinical standards of care, the maintenance and restoration of nutritional status is emerging as the foundation for HIV disease management.