1. Biological Relationship Between HIV and Nutrition Christine Wanke, MD AIDS 2012 - Turning the Tide Together

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

3. 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, 1992. Turner J, 1994.Wheeler DA, 1996, Wilson

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 BMI and Survival in HIV in South India, n=3262 Saghayam, unpublished 2008

5. Unintentional weight loss and mortality in ART treated (US) Amount of weight lostIncreased risk of mortality (%) Weight Loss > 10%5.8 (1.7-19.2) Weight loss 5-10%4.0 (1.5-10.8) Tang, 2002

6. 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

7. Weight Loss and Survival in Era of ART: Adapted from Tang AM, et al. JAIDS. 2002;31:230-236.

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

9. Frequency of Symptoms that may Contribute to Nutritional Compromise in HIV Infection in South India HIV positive (n=3855) NumberPer cent Fever167343.4 Weight loss145637.8 Diarrhea60725.7 Abdominal pain77520.1 Decreased appetite39020.1 Nausea20915.4 Vomiting43711.3 Tiredness/weakness/fatigue371 9.6 Dysphagia234 6.1 Fullness of stomach611.6 Saghayam, unpublished

10. Prevalence of Intestinal Dysfunction in HIV in South India HIV-HIV+CD4 < 100 cells/mm3 CD4 101- 350 cells/mm3 CD4> 350 cells/mm3 Abnormal D- xylose 44%42%70%50%32% R. Isaac, unpublished

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

12. Parameter HIV positive (n=62) HIV neg (n=22) CD4< 200 (n=44) CD4 >200 (n=18) BMI(kg/m 2 )19.1±3.920.7±3.821.9±4.5 MAC (cm)25.8±4.027.2±4.029.0±4.0 Waist (cm)74.2±10.575.8±10.777.8±10.7 Hip (cm)86.1±8.790.8±9.590.2±10.2 Waist hip ratio 0.86±0.00.83±0.00.86±0.07 Thigh (cm)39.8±5.743.4±7.544.9±6.6 TSF (mm)14.1±9.019.6±9.822.1±11.2 Fat %11.1±9.216.1±9.317.0±10.7 Nutritional Status in HIV Positive (Advanced and Early Disease) and HIV Negative Individuals in South India Saghayam unpublished

13. 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 20-62 years) 85% male Overall body weight increased mean 2.8 kg (range –12.5-22.5 kg) – 41 (22%) lost weight (>1 kg) – 37 (19%) were weight stable (change < 1 kg) – 112 (59%) gained weight (> 1 kg) Saghayam, unpublished

14. ParameterBaseline Mean ± SD (n=42) 6 months Mean ± SD (n=42) ‘z’ value ‘p’ value Body Weight (kg) 52.2 ± 11.7 55.4 ± 12.6 4.4670.000 BMI (kg/m 2 )19.2 ± 3.920.4 ± 4.34.4020.000 MAC (cm)26.0 ± 3.927.4 ± 3.84.0900.000 Waist (cm)74.3 ± 10.6 77.6 ± 11.5 4.7970.000 Hip (cm)86.3 ± 8.489.1 ± 9.24.3670.000 Waist hip ratio0.86 ± 0.00.87 ± 0.02.0520.040 Thigh (cm)39.9 ± 5.743.0 ± 5.85.1970.000 TSF (mm)14.1 ± 8.916.8 ± 10.3 2.9640.003 SSF (mm)17.8 ± 9.121.3 ± 11.0 3.5820.000 SISF (mm)12.4 ± 8.215.6 ± 11.2 3.5060.000 Impact of Treatment of HIV: Anthropometric Parameters after 6 months on HAART in South India

15. Impact of Opportunistic Infections on Nutritional Parameters in South India

16. 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