Treatment guidelines for HIV-associated wasting

Expert Consensus Statement on an Updated Definition of Unintended Weight Loss Among Persons With Human Immunodeficiency Virus in the Modern Treatment Era

The era of modern antiretroviral therapy (ART) has markedly improved health and survival among persons with human immunodeficiency virus (HIV) (PWH). In the pre-ART era, wasting was associated with HIV disease progression to acquired immunodeficiency syndrome and death. Effective ART has reduced the prevalence and incidence of this pre-ART form of HIV-associated wasting. However, a subgroup of ART-treated virally suppressed PWH continue to lose weight, often accompanied by aging-related comorbidities and/or functional deficits. For this subgroup of patients, the older definition of HIV-associated wasting (HIVAW) cannot and should not be applied. An expert panel comprising the authors of this white paper convened to review the existing definition of HIVAW and to create an updated definition that they termed HIV-associated weight loss, based on clinically defined parameters among contemporary PWH receiving ART. Here, clinical features and laboratory biomarkers associated with HIV-associated weight loss are reviewed and approaches to screening and treatment are considered. Available management approaches, including the use of current US Food and Drug Administration-approved medications for HIVAW and other available therapies are discussed. The expert panel also identified knowledge gaps and provided recommendations for clinicians, payers, and researchers.

The Prevalence of Hypogonadism and the Effectiveness of Androgen Administration on Body Composition in HIV-Infected Men: A Meta-Analysis

Background: Hypogonadism is a common comorbidity in human immunodeficiency virus (HIV)-infected men, although the real prevalence is difficult to be estimated. Moreover, in HIV settings, the efficacy of exogenous testosterone (Te) administration at improving body composition remains unclear. Aim of the study: This review has a double aim. First, to estimate the prevalence of pituitary–testis axis abnormality in HIV-infected patients compared to uninfected subjects. Second, to evaluate the effect of androgen administration on body composition in HIV-infected men. Materials and Methods: A systematic review of the literature and meta-analysis was carried out. Two separated literature searches were performed, the first to evaluate the prevalence of Te deficiency in HIV-infected men and the second one to evaluate effects of androgen administration on body composition. Results: The overall prevalence of Te deficiency in HIV-infected men was calculated from 41 studies, showing a 26% prevalence, which was even higher when free T (fT) levels, more than total T, were considered. Indeed, TT serum levels were similar between HIV patients and controls, although higher SHBG and lower fT were detected in HIV populations. When HIV-infected men were treated with exogenous Te, a significant increase in body weight, lean body mass and fat free mass was detected. Conclusion: The systematic review confirms the high prevalence of Te deficiency in HIV-infected men, particularly when fT has been considered. Moreover, chronic androgen supplementation improves body composition, affecting the lean mass compartment. However, considering the general frailty of HIV patients, a tailored indication for Te therapy should be advocated.

Energy expenditure in HIV infection

Energy intake recommendations for adults should be based preferably on direct measurements of total daily energy expenditure (TDEE) in corresponding populations who are maintaining healthy body weight and satisfactory physical activity levels. During adolescence, pregnancy, and lactation, energy requirements should be based on TDEE plus the additional energy required to advance these physiologic states. With illness, energy expenditure and energy intake change, but nutritional intervention is not necessarily beneficial. This article reviews data on energy expenditure in HIV infection with a focus on adults, adolescents aged ≥14 y, and pregnant and lactating women. Resting energy expenditure (REE) in adults with untreated asymptomatic HIV is ~ 10% higher than in healthy control subjects. In asymptomatic adults receiving antiretroviral therapy, REE may be similarly increased. HIV wasting and secondary infections are also associated with increased REE. In contrast, TDEE is typically normal in asymptomatic HIV and decreased in HIV wasting and secondary infection. No direct measurements of REE or TDEE are available in adolescents or in pregnant or lactating women with HIV. On the basis of current data, energy intake may need to increase by ~ 10% in adults with asymptomatic HIV to maintain body weight. In adolescents and in pregnant and lactating women with asymptomatic HIV, energy requirements should approximate recommendations for their uninfected counterparts until further data are available. In the resource-rich world, the energy expenditure changes associated with HIV are unlikely to contribute to significant weight loss. More data are needed on energy expenditure in HIV-infected populations from developing nations, where concurrent malnutrition and coinfections are common.

Self-reported psychological distress associated with steroid therapy for HIV

Anabolic androgenic steroid (AAS) replacement therapy is standard care for patients with low testosterone, including HIV-related conditions. These medications have been associated with development of aggressiveness, anxiety disorders, and depression, but only in short-term clinical trials. We conducted an anonymous street survey at a gay and lesbian community event and a survey in a clinic-based setting to study the wider prevalence of psychiatric side-effects associated with androgenic steroids. In the street-based survey, almost half of those prescribed AAS reported psychological side-effects, most commonly aggression (29%) followed by depression (21%). In the clinic survey of mostly HIV+ male patients, changes in sex drive were the most commonly reported effect of treatment while impulsive aggression, anxiety and depression were reported at levels similar to those in the street fair survey. These findings suggest that AAS therapy may be more frequently associated with distress than has been reported in the clinical literature.

HIV Wasting Syndrome in a Nigerian Failing Antiretroviral Therapy: A Case Report and Review of the Literature

The HIV wasting syndrome represented the face of HIV/AIDS before the advent of highly active antiretroviral therapy (HAART). Although the incidence of wasting has declined since the introduction of HAART, weight loss remains common in patients receiving HAART, especially in the setting of a failing HAART regimen. As we are not aware of any previous reports from Nigeria, we report a case of the classical wasting syndrome in a Nigerian female who had both virological and immunological HAART failure due to poor adherence. The influence of a failing HAART regimen, socioeconomic status, and other clinical variables in the wasting syndrome are discussed.

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.

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.