Management of Wasting

Syndrome on HIV/AIDS

Sub-Bagian Petri

Nuzirwan Acang
Bagian Ilmu Penyakit Dalam
Fakultas Kedokteran Unand
AIDS = Acquired Immune
Deficiency Syndrome
 Acquired - because it's a condition one must acquire or get
infected with, not something transmitted through the genes
 Immune - because it affects the body's immune system, the
part of the body which usually works to fight off germs such
as bacteria and viruses
 Deficiency - because it makes the immune system deficient
 Syndrome - because someone with AIDS may experience a
wide range of different diseases and opportunistic infections
 Top HIV/AIDS-Infected Countries
1. South Africa 9. United States
2. Nigeria 10. Russian Federation
3. Zimbabwe 11. China
Sub- Tanzania
Saharan
4.
12. Brazil
Africa 5. The Congo 13. Thailand
6. Ethiopia
7. Kenya
8. Mozambique

Source: Steinbrook R. The AIDS epidemic in 2004. NEJM. 2004;351:115-117.

AIDS Rates reported in 2002, US
Proportion of AIDS Cases, by Race/Ethnicity
West Sumatra, Indonesia
- December 2014 :
1.875 cases HIV/AID’S.
- XIXVth, among 33 Province in

Indonesia
DR. M. Djamil Hospital Padang
(October 2004-2006)
- AIDS : 63 Pts  death 50 Pts
 Modes of Transmission

Unprotected intercourse
Injection drug use
Other unsafe injections
Blood transfusions
Direct blood contact
Mother to child

Sources: 2004 Report on the global AIDS epidemic. Geneva: Joint United Nations Program on HIV/AIDS, July 2004.
Steinbrook R. The AIDS epidemic in 2004. NEJM. 2004;351:115-117.
CD4 Count in HIV infection
The CD4 cell , also known as "T4" or "helper T cell“ is
responsible for signaling other parts of the immune
system to respond to an infection.

Normal counts range from 500 to 1500 cells per cubic

millimeter of blood

Initially in HIV infection there is a sharp drop in the CD4

count and then the count levels off to around 500-600
cells/mm3. Wasting syndrome : < 200 cell/mm3

CD4 count is a marker of likely disease progression. CD4

percentage tends to decline as HIV disease progresses.
Natural History of Untreated HIV
Infection
 Manifestations of HIV Infection
Primary Infection Clinical Latency Advanced Disease

often asymptomatic or usually asymptomatic Symptomatic

overlooked
lymph nodes site of ongoing Plasma viremia begins to rise
symptoms 1-6 weeks after viral latency
infection CD4 cell count falls further
massive viral production
viral like syndrome: sore A decline in nutrient status or
throat, fever, destruction of CD4 cells body composition
lymphadenopathy, rash
a decrease in lean body mass Opportunistic infections
differential includes EBV, without apparent total body develop:
CMV, hepatitis, weight change fever, weight loss,
toxoplasmosis lymphadenopathy, thrush,
vitamin B12 deficiency diarrhea, malignancies,
antibody (ELISA, Western wasting syndrome, neurologic
Blot) may not be detected increased susceptibility to syndrome including dementia
food and water-borne
pathogens.
Opportunistic Infections
 Malnutrition
√ Contribute to impaired immune response
√ Result in more rapid disease progression &
shortened survival

√ Contribute to increased frequency and severity

of infections

√ Result in fatigue, loss of appetite, sense of taste

and smell, and decreased quality of life

√ Decrease tolerance to therapy and lessen

medication efficacy
‘The Wasting Syndrome’
The wasting syndrome is defined as
weight loss >10% of baseline body
weight with chronic fever, weakness, or
diarrhea, more than 30 days, in the
absence of other related illnesses
contributing to the weight loss.

‘unexplained weight loss’ believed to be

due to the HIV virus
 Pathophysiology AIDS Wasting
Oxidative Stress Micronutrient Deficiency Intestinal Parasites

Malabsorption/
Opportunistic
Immune Function Dysphagia
Infection

HIV

Pro-inflammatory Dietary Intake

Anorexia
Cytokines (TNF alpha)
Negative Energy
Metabolic Rate
Balance
Endocrine Disorder Fat Loss

Skeletal Protein Breakdown Protein Loss

J AIDS 1988
Potential Mechanisms of
AIDS Wasting
1) Decreased energy intake
2) Altered metabolism
3) Increase of sitokine
4) Hormonal Alterations
(Hipogonadism)
 Nutritional Problems
Decreased appetite may result from fever, pain,
fatigue, emotional stress, and altered sensations
of taste and smell due to medication side effects.
Lactose intolerance is an early effect of HIV on
the intestinal tract due to the loss of lactase. The
HIV infection changes the structure of the gut
wall, resulting in a decreased lactase level.
 Oral Lesions, caused by Candida albicans,
herpes, or Kaposi’s sarcoma can make chewing
and swallowing difficult and painful.
 Nutrional Problems (cont)
Diarrhea and malabsorption can result
from direct HIV infection in the intestine
but are more often caused by other
pathogens such as bacteria,
Crytosporidium, or herpes simplex that
take advantage of the depressed immune
system.
Medications can interfere with eating by
causing GI discomfort, nausea, vomiting,
diarrhea, and altered taste
 Nutrional Problems (cont)
Depression often leads to isolation,
apathy, neglect of self-care, and
diminished appetite – all which can affect
immunocompetence

Socioeconomic factors play an important

role in whether the patient can afford
adequate and nutritious food.
Medication Side Effects
 Anorexia
 Sore/dry/painful mouth
 Swallowing difficulties
 Constipation/Diarrhea
 Nausea/Vomiting/Altered Taste
 Depression/Tiredness/Lethargy
 Altered Metabolism
Early studies documented weight loss and protein
depletion in untreated patients

The application of HAART has lead to a decreased

incidence of malnutrition

Syndrome of altered body fat distribution has

emerged (lipodystrophy) associated with Pts

Hypertriglyceridemia, hypercholesterolemia, and

insulin resistance are commonly seen in patients
treated with HAART therapy.
HIV-Associated Lipodystrophy

Hyperlipidemia Insulin resistance

Fat Fat
accumulation atrophy
 Hormonal Factors
Testosterone deficiency: Testostereone levels have
been found to be markedly reduced in some HIV-
infected patients and a reduction in free serum
testosterone levels correlates closely with loss of
BCM.
Growth hormone resistance or deficiency: Many HIV-
infected patients with hypogonadism or malnutrition
display functional GH resistance.
Anabolic/Anti-catabolic agent
Important in maintaining protein balance and
muscle mass
Role of Micronutrients in the
Pathogenesis of HIV infection
 Micronutrients play important roles in maintaining
immune function and neutralizing the reactive oxygen
intermediates produced by activated macrophages and
neutrophils in their response to microorganism
 Micronutrient deficiencies are common among HIV
infected persons.
 Micronutrient deficiency has been associated with
further immunopression, oxidative stress, subsequent
acceleration of HIV replication and CD4+ T-cell
depletion. (semba)
MANAGEMENT OF WASTING SYNDROME
 Nutrition Care Process
Prioritize most urgent issues
Intervention goals
Prevent adverse events to therapies
Restore adequate nutritional status
Do Diet Prescription
 Nutrition Assessment
Height, Weight, BMI
– Use accurate techniques
– Check routinely – record and monitor change
– Body composition
• BMI
• Fat distribution changes
• Shape changes
RED FLAGS – wt change since last time and/or BMI <20
– Ask questions about why weight changes, look for clinical
signs of deficiencies/excesses
 Lab Values related to
nutrients
 Albumin
 Iron
 Lipid Profile
 Renal Function Tests
 Blood Sugar
 Diet Therapy

INDIVIDUALIZE!

Help maintain your health and quality of life

by having your nutrition reassessed

every 3-6 months.

 High-quality foods from all
the food groups
 Chicken, turkey, fish rich in omega-3’s (salmon, sardines,
mackerel), eggs, nuts, seeds, tofu, lentils, beans

HIV/AIDS: increase protein to fight fever & infections

Hepatitis C: keep protein at individual

recommended levels to spare your liver
 High-quality foods from all
the food groups

 Fruits & Vegetables: VARIETY is important

 Aim for as many colors and types of fruits and
vegetables possible
 Choose 100% juice for immune system support
 Diet Therapy
Fat
Varies in tolerance bases on individual
Assess fat for malabsorption – diarrhea
MCT to reduce steatorhea, abdominal cramps
Omega-3 fatty acids may improve immune function
Follow usual guidelines for elevated cholesterol & triglyceride
Include soluble fiber, plant sterols, soy protein, and cholesterol
saturated factors
 DIET THERAPY: Calories
500 calories above Energy Expenditure at Rest
(EER)
= 40-50 calories/kg

Example 180 pound man – 82 kgs = 3600

calories/day
 Diet Therapy: Protein
1.0 g/kg to 1.4 g/kg for maintenance
1.5 g/kg to 2.0 g/kg for replacing

Only restrict is severe liver or kidney

disease with doctors order
 Diet Therapy:
FLUIDS & ELECTROLYTES
Fluid = 30 to 35 ml/kg
During times of diarrhea extra fluid (2
cups/day) and electrolytes for night
sweats, diarrhea, and fever
 Pedialyte, kool-ade with salt, jello, broth
 Diet Therapy:
Vitamins and Minerals

 Actual status is seldom identifiable in labs

 Gather patient self-reported intake
 Suggest 100% One-A-Day with minerals (calcium, Iron,
Magnesium)
 Suggest Basic Vitamin B-Supplement
 Go for higher doses if diarrhea is prolonged, anemia
develops or dietary deficiencies are evident
 Macronutrients VS.
Micronutrients

MACRO
MICRO
Carbohydrate
Vitamins
Protein
Minerals
Fat
Antioxidants
Water
 Diet Prescription
 Increase calories
 Increase protein
 Increase fiber
 Increased fruit and veggies
 Food safety
 Drug-nutrient interactions
 Perhaps anti-diarrheal, pancreatic or lactase enzymes
 Role of Micronutrients in the
Pathogenesis of HIV infection
Micronutrients play important roles in
maintaining immune function and SLOW
reactive oxidant destruction
Micronutrient deficiencies are common among
HIV infected persons – nature of disease and
malnutrition
Micronutrient deficiency has been associated
with further immunopression, oxidative stress,
speeds up HIV replication and CD4+ T-cell
depletion. (semba)
 Vitamin E and C
Supplements of vitamin E &C reduce oxidative
stress in HIV and produce a trend towards a
reduction in viral load.

This is worthy of larger clinical trials, especially in

HIV-infected persons who cannot afford new
combination therapies
 Aids - 10 September 1998 - Volume 12 - Issue 13 - p 1653-1659
 Farmacologic
Appetite Stimulant: Megestrol Acetate
(Megace)
 A synthetic derivative of the natural steroid hormone,
progesterone. Dose : 200-1600 mg/day
 Improved appetite in a number of studies
 Takes two weeks for effect.
 Considerable increases in BW, although mostly in body fat
 May be due to testosterone lowering effect, not reversed
by supplementation w/testosterone
 May induce or exacerbate DM, cause adrenal insufficiency
when abruptly discontinued after long-term use

Treatment Guidelines for HIV Associated Wasting, Mayo Clinic Proceedings, April 2000
 Farmacologic :
Appetite Stimulant : Dronabinol
Derived from delta-9-tetrahydrocannabinol
(major active component of Marijuana)
Useful in decreasing nausea and increasing
appetite
Insignificant gains or even loss of total BW
May induce central nervous system events
such as anxiety, confusion, emotional lability
and hallucinations, possibly addictive.

Treatment Guidelines for HIV Associated Wasting, Mayo Clinic Proceedings, April 2000
 Testosterone & Testosterone
Analogues
About half of men with advanced HIV have
androgen deficiency.
May contribute to muscle wasting.
May be due to effects of undernutrition, chronic
illness, or medications such as Megesterol
acetate’s effect on gonadotropin secretion.
Most studies have shown IM testosterone
supplementation to result in wt gain, increased
LBM, overall feeling of well-being.

Treatment Guidelines for HIV Associated Wasting, Mayo Clinic Proceedings, April 2000
 (Cont………)
Studies of testosterone analogues show varied
efficacy in improving nutritional status but may
carry risks for hepatic toxic effects:
Nandrolone decanoate 100mg/mL IM q 2wks =
increased BW, LBM and quality of life.
Oxymethalone 150 mg/day found to have similar
results
Testosterone cypionate 200mg IM q 2wks for 3
mos, no result except for increased quality of life.
 Growth Hormone
AIDS pts may be growth hormone resistant. In
studies of GH in AIDS pts, doses used are
significantly higher than those required for
replacement.
GH has been shown to increase LBM and
protein synthesis and reduce urinary nitrogen
excretion.
GH costs ~$18,000/yr but Medicaid has
approved reimbursement, making this therapy
more accessible.
 (Cont……………)
Short-term use of growth hormone (12 wks) has
effects on wt gain that persist after therapy is
discontinued.
Using GH for short periods when required, rather
than as continuous therapy will minimize costs
while maximizing patient nutritional status.
Indicated for use when all other methods have
failed and Pts has normal testosterone levels or
on replacement testosterone for at least 4-6 wks.
Contraindicated if Pts has malignancy
 Resistance Training
Supervised exercise training is a promising
anabolic strategy for pts with AIDS.
Studies of exercise training have shown increased
muscle function, wt gain, strength, LBM.
Effects of resistance training alone in AIDS
wasting pts remains unknown.
However, use of resistance training with
testosterone and oxandralone has been shown to
be effective in AIDS pts with AIDS wasting.
Resistance Training (cont)
Strawford, et al studied 24 eugonadal men
with HIV associated wt loss. All subjects
received supervised progressive resistance
exercise with physiologic IM testosterone
replacement 100 mg/wk to suppress
endogenous testosterone for 8 weeks.
Randomization was between anabolic
steroid, oxandralone, 20 mg/day and placebo.

Journal of the American Medical Association, April 14 1999

 Summary
HIV/AIDS remains an epidemic worldwide
Malnutrition is a complication in HIV related
morbidity and mortality
Weight loss is an independent predictor of
mortality
Contributors of AIDS wasting syndrome
include decreased energy intake, altered
metabolism, and hormonal factors
Management of wasting syndrome are
nutritional support and appetite stimulant
Nutrition Assessment - Physical
Height, Weight, BMI

– Use accurate techniques

– Check routinely – record and monitor change
– Body composition
• BMI
• Fat distribution changes
• Shape changes
RED FLAGS – wt change since last time and/or BMI <20
– Ask questions about why weight changes, look for clinical
signs of deficiencies/excesses
 Lab Values related to
nutrients
 Albumin
 Iron
 Lipid Profile
 Renal Function Tests
 Blood Sugar
 Discussion

Questions?