Janet E. Forrester

Weight Loss and Wasting Remain Common Complications in Individuals Infected with Human Immunodeficiency Virus in the Era of Highly Active Antiretroviral Therapy

It has been postulated that the use of highly active antiretroviral therapy (HAART) would reduce the occurrence of human immunodeficiency virus (HIV)-associated weight loss and wasting. To test this assumption, we evaluated, by means of longitudinal analysis, a prospective cohort of 469 HIV-infected individuals enrolled in a study of the impact of HIV on nutrition. Overall, 156 individuals in the cohort (33.5%) met at least 1 of these definitions of wasting. Furthermore, 58% of the cohort (289 patients) lost >1.5 kg of weight in a 6-month period between any 2 study visits. More than 50% of the cohort was receiving HAART at the time that they met 1 of the definitions of wasting; with regard to the occurrence of wasting; no differences were related to therapy.

Weight loss and survival in HIV-positive patients in the era of highly active antiretroviral therapy.

Weight loss and wasting have long been established as strong predictors of mortality in HIV-infected patients. Today, despite the effectiveness of highly active antiretroviral therapy (HAART), there is evidence that HIV-related wasting is still an important comorbidity in many patients. We conducted a study to determine if wasting is still associated with decreased survival in patients receiving HAART and which parameter (weight, fat-free mass [FFM], body cell mass [BCM], or fat mass [FM]) is most strongly associated with mortality. The study population consisted of 678 HIV-positive participants enrolled in the Nutrition for Healthy Living study. Weight, FFM, BCM, and FM were assessed for all participants at 6-month intervals. At each follow-up visit, percent losses of each parameter were calculated from values at baseline and the previous visit. Cox proportional hazards models were used to estimate and compare the relative risks of death for each parameter, adjusting for potential confounders such as HAART use, body mass index, and CD4 cell counts. In analyses examining the parameters separately and together in the same model, weight loss emerged as the strongest independent predictor of mortality. Weight loss of >or=10% from baseline or the previous visit was significantly associated with a four- to sixfold increase in mortality compared with maintenance or gaining of weight. Even one episode of weight loss of >or=3% from baseline or >or=5% from the previous visit was predictive of mortality. In summary, despite the apparent benefits of HAART use on HIV-related survival, weight loss remains an independent predictor of mortality. In addition, FFM or BCM estimated using bioelectrical impedance analysis does not add further prognostic value over weight loss.

Micronutrient levels and HIV disease status in HIV-infected patients on highly active antiretroviral therapy in the Nutrition for Healthy Living cohort.

Background:Low serum micronutrient levels were common before widespread use of highly active antiretroviral therapy (HAART) and were associated with adverse outcomes. Few data are available on micronutrient levels in subjects taking HAART. Objective:To determine the prevalence of low serum retinol, α-tocopherol, zinc, and selenium in HIV-infected subjects taking HAART and to assess the association of micronutrient levels with HIV disease status. Design:Cross-sectional. Setting:Nutrition for Healthy Living (NFHL) study. Participants:HIV-infected subjects on HAART. Methods:Retinol, α-tocopherol, zinc, and selenium were determined in frozen serum samples from 171 men and 117 women. Low serum levels were defined as retinol <30 μg/dL, selenium <85 μg/L, α-tocopherol <500 μg/dL, and zinc <670 μg/L. Association of micronutrient quartiles with CD4 cell count, CD4 count <200 cells/mm3, HIV viral load (VL), and undetectable VL was assessed using adjusted multivariate regression. Results:Five percent of men and 14% of women had low retinol, 8% of men and 3% of women had low selenium, and 7% of men and no women had low α-tocopherol. Forty percent of men and 36% of women had low zinc, however. Subjects in the upper quartiles of zinc had lower log VL levels than those in the lowest quartile (significant for women). Subjects in the upper quartiles of selenium also tended to have lower VL levels compared with those in the lowest quartile. Surprisingly, women in the upper quartiles of retinol had higher log VLs than those in the lowest quartile. There was no significant association of any micronutrient with CD4 cell count or likelihood of CD4 count <200 cells/mm3. The level of CD4 cell count influenced the association of retinol with log VL in men, however. In men with CD4 counts >350 cells/mm3, those with higher retinol had higher log VLs compared with the lowest quartile, whereas in men with CD4 counts <350, those with higher retinol levels had lower log VLs compared with the lowest quartile. Conclusions:Low retinol, α-tocopherol, and selenium are uncommon in HIV-infected subjects on HAART. Zinc deficiency remains common, however. Decreased retinol levels in women and in men with CD4 counts >350 cells/mm3 and increased zinc and selenium levels in both genders may be associated with improved virologic control.

Predisposition of individuals and families in Mexico to heavy infection with Ascaris lumbricoides and Trichuris trichiura.

Stool specimens from 90% of the population of 2 marginal communities in Coatzacoalcos, Mexico, were examined by the Kato-Katz technique for the estimation of eggs per gram of faeces (epg). Average epg values for Ascaris lumbricoides and Trichuris trichiura were calculated for each family in the community, based on the arithmetic mean epg of family members for each parasite. 39 families were classified as either lightly or heavily infected with A. lumbricoides and infected members were treated with mebendazole. A. lumbricoides expelled following treatment were collected from the children 2-10 years of age, and reinfection was monitored monthly for 6 months. At the end of the reinfection interval, a final stool specimen was collected from all family members and those infected were treated. Again, A. lumbricoides expelled by the children 2-10 years of age were collected. There was a significant correlation between the number of A. lumbricoides expelled by the children at the first and second treatments as well as in epg values before the first and second treatments for both A. lumbricoides and T. trichiura in children (2-10 years) and adults (greater than 19 years). At the family level, there were significant correlations between the values of family mean epg before each treatment for both A. lumbricoides and T. trichiura.

Nutrient intake and body weight in a large HIV cohort that includes women and minorities

OBJECTIVE Evaluate the baseline nutrient intake of an HIV positive population that includes significant representation from women and minorities, and determine the relationship between state of disease and nutritional intake. DESIGN Baseline data from a prospective study (Nutrition for Healthy Living). SUBJECTS Individuals with HIV in the Boston and Rhode Island area (n = 516); 25% were women and 30% were minorities. METHODS Nutrient intakes from 3-day food records, which included vitamin/mineral supplements, were estimated by gender and nonwhite vs white categories, after grouping by CD4 lymphocyte counts. STATISTICAL ANALYSES Spearman correlation coefficients, Wilcoxon signed rank test, Wilcoxon rank sum test, chi2 test, and restricted cubic spline model were used for data analyses as indicated. RESULTS Macronutrient but not micronutrient intake was statistically and inversely associated with decreasing CD4 cell counts. The median intake of micronutrients was higher in the study sample compared with the same age and gender group in NHANES III data; however, 25% to 35% of the women in our study sample had dietary intakes of less than 75% of the DRIs for vitamins A, C, E and B-6, and iron and zinc. White men had statistically higher values of all micronutrients compared with nonwhite men. Body mass index for men and women ranged from 23 to 25. CONCLUSIONS/APPLICATIONS Median values for micronutrient intake from food plus vitamin/mineral supplements were adequate in the overall population studied, but a large percent of women and minorities had inadequate nutrient intakes and would benefit from dietary assessment and counseling.

Weight and body composition in a cohort of HIV-positive men and women.

OBJECTIVE At issue is whether weight loss in HIV infection is a cachectic process, characterised by loss of lean body mass with conservation of fat, or a process of starvation. We present data on body composition from 516 persons at different stages of HIV infection as determined by CD4 counts. DESIGN Cross-sectional analyses of body composition in relation to CD4 count. SETTING The baseline data from a prospective cohort study of outcomes in HIV/AIDS in relation to nutritional status in Boston, Massachusetts, USA. SUBJECTS : The first 516 subjects with HIV/AIDS to enroll in the study. RESULTS Differences in weight in relation to CD4 counts were present only at CD4 counts of 600 or less (slope below : 1.9 kg per 100 CD4 cells, On average, 68% of the difference in weight over CD4 counts was fat (slope: 1.3 kg fat per 100 CD4 cells, CONCLUSIONS This cross-sectional analysis suggests that weight loss consists principally of fat loss in those persons with adequate fat stores. This observation will need to be confirmed in longitudinal analyses.

Measurement of Ascaris lumbricoides infection intensity and the dynamics of expulsion following treatment with mebendazole.

Intensity of Ascaris lumbricoides infection was measured in terms of egg counts and worm burden in children 2-10 years of age. The expulsion of A. lumbricoides with a 3-day treatment of mebendazole occurred over 8 days, beginning on the second day of treatment. Ninety-seven percent of the worms were expelled between the second and seventh days. A rapid means of estimating eggs per gram (epg) by the Kato Katz technique correlated well with the method described by Martin & Beaver (1968). In spite of apparent density dependence in egg production, A. lumbricoides egg counts correlated well with worm burdens. It is concluded that, within the context of community surveys, epg is a reasonable means of identifying heavily infected individuals and that epg can be estimated rapidly by a slight modification to the standard Kato Katz technique.

Body composition and dietary intake in relation to drug abuse in a cohort of HIV-positive persons.

&NA;We examined the relationships between drug abuse, weight, body composition, and dietary intake in persons infected with HIV in a cross‐sectional analysis of baseline data from a longitudinal study of nutritional status and HIV. Body composition was measured by bioelectrical impedance analysis. Dietary data were collected by 3‐day food records or 24‐hour recalls. We analyzed data from 39 current intravenous drug users (IVDU), 103 past intravenous drug users (past‐IVDU), 239 users of nonintravenous drugs (users‐NIVD), and 61 nonusers (reference category). In the men, there were no differences in weight, body mass index (BMI), or body composition among the drug‐use groups. In the women, there was a trend to lower weight and BMI across the drug use categories: IVDU women had lower average weight (‐13.7 kg; p = .006), BMI (‐5.6 units; p = .003) and less fat mass than non‐users (‐9.8 kg; p = .0001). In women, drug users had higher weight‐adjusted energy intakes than nonusers, whereas in the men both drug using groups, NIVD and IVDU, had higher energy intakes than nonusers. These data suggest that intravenous drug‐abuse is associated with lower weight and fat mass in women with HIV infection despite adequate self‐reported energy intake.

Micronutrients in HIV/AIDS: is there evidence to change the WHO 2003 recommendations?

To establish whether there is new evidence to inform changes to WHO 2003 recommendations for micronutrient intake in persons with HIV/AIDS, we conducted a narrative review of the literature published from 2003 to 2010. Although the review focused on new randomized controlled trials of multiple micronutrients in HIV-infected adults, including pregnant and lactating women, we also considered randomized trials of single micronutrients. The review found that there are few published randomized controlled trials of micronutrients in HIV-infected persons and that most trials used high-dose multiple micronutrient supplementation. The trials were heterogeneous with respect to the composition and dose of micronutrients used and the target population studied. Despite this heterogeneity, 5 of 6 trials that used high-dose multiple micronutrients showed benefits in terms of either improved CD4 cell counts or survival. However, many of these trials were small and of short duration, and therefore the long-term risks and benefits of high-dose multiple micronutrients are not established. The current WHO recommendation for an intake of micronutrients at Recommended Dietary Allowance amounts continues to be a reasonable target for persons with clinically stable HIV infection. In light of new data that show adverse effects of high-dose vitamin A, the current recommendation for a single high dose of vitamin A in HIV-infected women within 6 wk of delivery should be reviewed.

Randomised trial of albendazole and pyrantel in symptomless trichuriasis in children

BACKGROUND We aimed to find out whether symptomless infection with Trichuris trichiura is associated with impairment of growth and to assess the effect of a multiple-doses regimen of anthelmintic drugs on the growth of children. METHODS In a community based trial, 622 Mexican children were randomly allocated one of three treatment regimens: 3 days of albendazole 400 mg daily (high efficacy); one dose of albendazole 400 mg (moderate efficacy); one dose of pyrantel (pyrantel embonate) 11 mg/kg (low efficacy). Growth was monitored for 12 months. Analyses were by intention to treat. FINDINGS 113 (18%) children were lost to follow-up--34 from the pyrantel group, 45 from the albendazole 400 mg group, and 34 from the albendazole 1200 mg group. Among the 127 children with heavy pretreatment infections, albendazole 1200 mg was better than pyrantel in terms of an increase in arm circumference (mean 0.26 cm, p=0.044). Among the 381 children with low pretreatment levels of infection, changes in weight (mean difference between groups -0.33 kg, p=0.036), arm circumference (-0.18 cm, p=0.0095), and thickness of triceps skinfold (-0.41 mm, p=0.0031) were less in children on albendazole 1200 mg than in those on pyrantel. INTERPRETATION Symptomless trichuriasis impairs growth and albendazole or pyrantel may affect growth, independently of a therapeutic action on parasites. Possible toxic effects of high-dose albendazole require further investigation.