PEPFAR

Biological Relationship Between HIV and Nutrition

Christine Wanke, MD

AIDS 2012 - Turning the Tide Together

Malnutrition in HIV

Malabsorption

Diarrhea

MalnutritionFurther 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, 1992. 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Saghayam, unpublished 2008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 lost Increased risk of mortality (%)

Weight Loss > 10% 5.8 (1.7-19.2)

Weight loss 5-10% 4.0 (1.5-10.8)

Tang, 2002

Nutritional status at initiation of ART: association with mortality

region Increased risk of death

Moderate to severe malnutrition

Singapore 2.2

BMI < 16kg/m2 Zambia 2.4

BMI <15.9 kg/m2 Malawi 6 .0

BMI < 16 Kg/m2 Tanzania 2.0

Paton 2006, Stringer 2006, Zaccharia 2006, Johannsesen 2008

Weight Loss and Survival in Era of ART:

Adapted from Tang AM, et al. JAIDS. 2002;31:230-236.

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)

Number Per cent

Fever 1673 43.4

Weight loss 1456 37.8

Diarrhea 607 25.7

Abdominal pain 775 20.1

Decreased appetite 390 20.1

Nausea 209 15.4

Vomiting 437 11.3

Tiredness/weakness/fatigue 371 9.6

Dysphagia 234 6.1

Fullness of stomach 61 1.6

Saghayam, unpublished

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R. Isaac, unpublished

-1

-0.5

0

0.5

1

1.5

1 2

Cha

nge

in w

eigh

t (kg

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BM

I (kg

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)

<-1 (-1) to (+1) >+1

Categories of change in HIV viral loads

Change in body weight and BMI by categories of change in viral load: untreated HIV

Weight

BMI

(p<0.001)

(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/m2) 19.1±3.9 20.7±3.8 21.9±4.5

MAC (cm) 25.8±4.0 27.2±4.0 29.0±4.0

Waist (cm) 74.2±10.5 75.8±10.7 77.8±10.7

Hip (cm) 86.1±8.7 90.8±9.5 90.2±10.2

Waist hip ratio

0.86±0.0 0.83±0.0 0.86±0.07

Thigh (cm) 39.8±5.7 43.4±7.5 44.9±6.6

TSF (mm) 14.1±9.0 19.6±9.8 22.1±11.2

Fat % 11.1±9.2 16.1±9.3 17.0±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 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

Parameter BaselineMean ± SD

(n=42)

6 monthsMean ± SD

(n=42)

‘z’ value

‘p’ value

Body Weight (kg)

52.2 ± 11.7

55.4 ± 12.6

4.467 0.000

BMI (kg/m2) 19.2 ± 3.9 20.4 ± 4.3 4.402 0.000

MAC (cm) 26.0 ± 3.9 27.4 ± 3.8 4.090 0.000

Waist (cm) 74.3 ± 10.6

77.6 ± 11.5

4.797 0.000

Hip (cm) 86.3 ± 8.4 89.1 ± 9.2 4.367 0.000

Waist hip ratio 0.86 ± 0.0 0.87 ± 0.0 2.052 0.040

Thigh (cm) 39.9 ± 5.7 43.0 ± 5.8 5.197 0.000

TSF (mm) 14.1 ± 8.9 16.8 ± 10.3

2.964 0.003

SSF (mm) 17.8 ± 9.1 21.3 ± 11.0

3.582 0.000

SISF (mm) 12.4 ± 8.2 15.6 ± 11.2

3.506 0.000

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