Biological Relationship Between HIV and Nutrition Christine Wanke, MD AIDS Turning the Tide Together

Malnutrition in HIV Malabsorption Diarrhea Malnutrition Further Immune Dysfunction Increased risk for enteric pathogens Intestinal injury

Weight loss pre-ART Death associated with weight less than 66% of ideal body weight Death associated with lean body mass falling below 54% Independent risk factor for death in HIV Weight loss also associated with increased risk for hospitalization, decreased quality of life Increased progression of HIV As little as 5% weight loss was associated with mortality and increased risk of opportunistic infection.. Chlebowski RT, 1989; 6. Guenter P, 1993; Palenicek JP, 1995;.Cohan GR, Turner J, 1994.Wheeler DA, 1996, Wilson

BMI and Survival in HIV in South India, n=3262 Saghayam, unpublished 2008

Unintentional weight loss and mortality in ART treated (US) Amount of weight lostIncreased risk of mortality (%) Weight Loss > 10%5.8 ( ) Weight loss 5-10%4.0 ( ) Tang, 2002

Nutritional status at initiation of ART: association with mortality regionIncreased risk of death Moderate to severe malnutrition Singapore2.2 BMI < 16kg/m2Zambia2.4 BMI <15.9 kg/m2Malawi6.0 BMI < 16 Kg/m2Tanzania2.0 Paton 2006, Stringer 2006, Zaccharia 2006, Johannsesen 2008

Weight Loss and Survival in Era of ART: Adapted from Tang AM, et al. JAIDS. 2002;31:

Etiology of Weight Loss in HIV : Inadequate Caloric Intake – Symptoms – Access to food/ food security – Malabsorption/ diarrhea Altered Metabolism – HIV – Opportunistic Infections

Frequency of Symptoms that may Contribute to Nutritional Compromise in HIV Infection in South India HIV positive (n=3855) NumberPer cent Fever Weight loss Diarrhea Abdominal pain Decreased appetite Nausea Vomiting Tiredness/weakness/fatigue Dysphagia Fullness of stomach611.6 Saghayam, unpublished

Prevalence of Intestinal Dysfunction in HIV in South India HIV-HIV+CD4 < 100 cells/mm3 CD cells/mm3 CD4> 350 cells/mm3 Abnormal D- xylose 44%42%70%50%32% R. Isaac, unpublished

Change in body weight and BMI by categories of change in viral load: untreated HIV Weight BMI (p<0.001) Mwamburi et al 2004

Parameter HIV positive (n=62) HIV neg (n=22) CD4< 200 (n=44) CD4 >200 (n=18) BMI(kg/m 2 )19.1± ± ±4.5 MAC (cm)25.8± ± ±4.0 Waist (cm)74.2± ± ±10.7 Hip (cm)86.1± ± ±10.2 Waist hip ratio 0.86± ± ±0.07 Thigh (cm)39.8± ± ±6.6 TSF (mm)14.1± ± ±11.2 Fat %11.1± ± ±10.7 Nutritional Status in HIV Positive (Advanced and Early Disease) and HIV Negative Individuals in South India Saghayam unpublished

Does 6 months of ART Improve Nutritional Status in HIV in India? 190 HIV-infected patients initiating HAART in Chennai, South India at YRG CARE Mean age 35 years (range years) 85% male Overall body weight increased mean 2.8 kg (range – kg) – 41 (22%) lost weight (>1 kg) – 37 (19%) were weight stable (change < 1 kg) – 112 (59%) gained weight (> 1 kg) Saghayam, unpublished

ParameterBaseline Mean ± SD (n=42) 6 months Mean ± SD (n=42) ‘z’ value ‘p’ value Body Weight (kg) 52.2 ± ± BMI (kg/m 2 )19.2 ± ± MAC (cm)26.0 ± ± Waist (cm)74.3 ± ± Hip (cm)86.3 ± ± Waist hip ratio0.86 ± ± Thigh (cm)39.9 ± ± TSF (mm)14.1 ± ± SSF (mm)17.8 ± ± SISF (mm)12.4 ± ± Impact of Treatment of HIV: Anthropometric Parameters after 6 months on HAART in South India

Impact of Opportunistic Infections on Nutritional Parameters in South India

Summary Weight loss in HIV is associated with morbidity and mortality – Whether or not on ART Weight loss is likely multifactorial Response needs to consider etiology – Treatment of HIV – Treatment of OIs (TB) – Control of symptoms