Waste Not, Want Notaa

Waste Not, Want Not

Wasting -- also known as cachexia -- was a prominent feature of AIDS in the early years of the epidemic; even today, AIDS is referred to as "slim disease" in Africa. Experts define wasting as involuntary or unwanted loss of 10% or more of body weight. As Steven Grinspoon, MD, and Kathleen Mulligan, MD, discuss in an April 2003 special issue of Clinical Infectious Diseases (CID) devoted to nutrition and HIV, "wasting ... has been associated with increased mortality, accelerated disease progression, loss of muscle protein mass, and impairment of strength and functional status." Even a 5% loss has been linked to increased illness and death.

In classic HIV-related wasting, lost weight is in the form of lean body mass rather than fat, especially in men. People with HIV/AIDS (and other chronic illnesses) require more calories simply to maintain their weight, due to increased metabolism, higher energy demands, hormone and cytokine imbalances, inefficient absorption and utilization of nutrients, and/or accelerated tissue breakdown (catabolism).

While effective antiretroviral therapy has dramatically reduced the incidence of severe wasting, moderate weight loss is still a prominent feature of HIV disease. For example, as reported in the September 1, 2005 Journal of Acquired Immune Deficiency Syndromes (JAIDS), Alice Tang, MD, from Tufts University Medical School and colleagues found a steady increase in the rate of 5% or greater loss of body weight between 1995-1997 (pre-HAART) and 1998-2003 (HAART era). In an analysis of 713 HIV positive participants in the Nutrition for Healthy Living cohort, 53% lost at least 5% of their body weight during any six-month period. Weight loss was significantly associated with nausea, diarrhea, thrush, poverty, history of drug use, CD4 cell count below 200 cells/mm³, and HIV viral load above 100,000 copies/mL. The authors were unable to pinpoint the reasons for the increased rate of wasting in the HAART era.

In another study (reported in the October 15, 2005 issue of CID), Adriana Campa, PhD, from Florida International University and colleagues found that 17.6% of 119 HIV positive, mostly homeless drugs users in Miami showed evidence of HIV-related wasting. In this study, wasting was associated with cocaine and heavy alcohol use, "food insecurity" (not eating for one or more days in the past month), and higher HIV viral load. Participants taking HAART were more likely to experiencing wasting than those not receiving anti-HIV treatment (86% vs 67%).

Rather than dramatic whole-body weight loss, today many HIV positive people on HAART experience lipoatrophy, or fat loss in the face, limbs, and buttocks. Paradoxically, this may coincide with fat accumulation in other areas of the body (discussed below). Lipoatrophy is most strongly associated with use of nucleoside reverse transcriptase inhibitors (NRTIs), especially d4T (stavudine or Zerit). For this reason, U.S. government treatment guidelines no longer recommend d4T as part of a first-line regimen for people starting HAART.