Long-term impact of HIV-associated wasting

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HIV-associated wasting can have a long-term impact on physical function and quality of life, according to research from the US. The research was conducted by investigators from the Multicentre AIDS Cohort Study.

HIV-positive men with a wasting diagnosis were assessed an average of four years after their wasting diagnosis and compared with HIV-positive and HIV-negative men without wasting. “The degree of impairment observed among HIV/wasting men may have significant clinical implications,” comment the authors. “HIV-wasting had a similar effect of 10–20 years of ageing on self-reported physical QoL 9quality of life).”

HIV-wasting syndrome was recognised early in the epidemic. Diagnostic criteria are involuntary weight loss of over 10%, either chronic diarrhoea or weakness and fever for over one month. Chronic weight loss and wasting are still among the commonest manifestations of advanced HIV disease. Although the incidence of wasting has declined marked with the introduction of effective antiretroviral therapy, initial weight loss may not be restored even with effective HIV therapy.

Because the long-term consequences of HIV-associated wasting are still unclear, investigators from MACS designed a longitudinal study comparing the physical function and physical and mental quality of life of HIV-positive wasting survivors with HIV-positive and HIV-negative men without wasting. The impact of wasting on overall survival was also monitored.

Patients with wasting were assessed at least two years after they were diagnosed with the syndrome or other manifestations of severe weight loss (BMI below 18.5kg/m2, sustained 10% loss in body weight, or a 1%/kg loss of body weight each year during follow-up). Men with wasting were matched with men of a similar age who were recruited to the cohort at approximately the same time. CD4 count and viral load were used for matching with HIV-positive men.

Assessments of physical function included grip strength and walking speed. Physical and mental quality of life were assessed using accredited self-administered questionnaires.

Median survival was significantly lower among MACS patients with HIV-related wasting (9.1 years) compared to HIV-positive men without wasting (11.6 years). “We found that the occurrence of HIV-wasting by any of our tested definitions was associated with markedly shorter survival than observed among HIV-infected men without wasting or uninfected men,” comment the investigators.

The study population for the assessment of the impact of wasting on physical function and quality of life comprised 85 men with a wasting diagnosis, 249 men with HIV and no wasting and 338 HIV-negative men. Most of the study visits (80%) took place after 1996 – the year in which effective HIV therapy became widely available. Men with wasting were assessed a median of four years after they were diagnosed with the syndrome. During this time, they experienced a small but significant increase in total body weight. However, they still weighed between 8-9kg less than men without wasting.

“We suspect that wasting in our cohort was associated largely with losses in lean mass, with subsequent regain largely representing fat mass,” comment the investigators. “The persistent low body weight and mean gain of only 2kg over 4 years is of particular concern in regards to long-term consequences in our cohort.”

At the time of assessment, the men with wasting had more co-morbid health conditions (2 vs.1), greater levels of use of stavudine (d4T) – an antiretroviral associated with fat loss (69% vs. 54%; cumulative use 2 years vs .05 years), and greater levels of use of therapy to counter wasting (testosterone – 38% vs. 22%).
Men with HIV-associated wasting had lower grip strength and poorer physical quality of life than HIV-positive men without wasting (p < 0.03), and poorer physical quality of life but higher mental quality of life compared to HIV-negative men (p < 0.05). Walking speed did not differ significantly between the wasting and non-wasting patients. When comparison was limited to patients with HIV, the association between wasting and physical quality of life ceased to be significant when lowest ever CD4 count and an AIDS diagnosis were taken into account. The association between wasting and grip strength was of borderline significance (p = 0.055), a likely reflection of the small sample size.

“HIV-wasting has a negative impact on muscle strength and physical QoL, years after stabilisation of body weight,” conclude the investigators. “Prior studies have demonstrated that low body weight and/or poor strength are associated with low bone density, injurious falls, fractures, frailty, and ultimately, could result in a loss of independent living.”

Abstract
Background: The long-term consequences of wasting among HIV-infected persons are not known.
Design: HIV-infected participants surviving >=2 years based on Kaplan-Meier analysis after a clinical diagnosis or weight trajectory consistent with wasting and with available physical function assessment data [grip strength, gait speed, and quality of life (QoL)] were matched to HIV-infected and uninfected men without wasting.
Methods: Matching criteria at the functional assessment included age, calendar year, and CD4 cell count and plasma HIV-1 RNA (HIV-infected only). Multivariable linear regression analyses adjusted for age, cohort, race, hepatitis C status, and number of comorbid illnesses were used to assess the impact of wasting on subsequent physical function.
Results: Among 85 HIV-infected men surviving >=2 years after wasting, we evaluated physical function outcomes compared with 249 HIV-infected and 338 HIV-uninfected men with no historical wasting. In multivariable regression models, HIV-infected men with prior wasting had lower grip strength and poorer physical QoL than HIV-infected men with no wasting (P <= 0.03), and poorer physical QoL, but higher mental QoL than HIV-uninfected men (P <= 0.05). When controlling for measures of immune suppression (nadir CD4/AIDS, the association between wasting and physical QoL was markedly attenuated, whereas there was minimal impact on the association between wasting and grip strength.
Conclusions: HIV-infected wasting survivors had weaker grip strength compared with HIV-infected persons without wasting; immune suppression was associated only with physical QoL. HIV-infected survivors of wasting may represent a population of adults at increased risk for physical function decline.

Aidsmap material
AIDS abstract


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