Damage Control

Even with advances in treatments that have helped improve the lives of many of the more than 1 million Americans estimated to be living with HIV, the condition of HIV-related wasting remains a significant problem. West Hollywood, Calif., mayor John Duran is someone who has struggled with this problem. Several years after he was diagnosed with HIV, Duran experienced a rapid 60-pound drop in weight, most of which he attributed to the loss of muscle mass. He discovered that his sudden involuntary weight loss was the result of wasting. 'I was surprised to learn that my sudden weight loss was a result of HIV and that HIV wasting is a common effect of the disease,' Duran says. 'I want people to know that HIV wasting does not have to impact your daily life. Managing the symptoms of this condition is important to managing your health and an essential part of feeling good about yourself. It gave me the self-confidence to accomplish my dreams.' In fact, Duran's election to the West Hollywood city council in March 2001--while being public about his HIV infection--was the continuation of a long and dedicated history of service to the West Hollywood community. Understanding Wasting The Centers for Disease Control and Prevention definition of HIV wasting was developed in 1987 as 'the involuntary loss of at least 10% of ideal body weight with associated symptoms of chronic fever, weakness, or diarrhea in the absence of other related illnesses that could contribute to the weight loss.' People with wasting may also experience loss of lean body mass, depending on their gender. For example, early studies of men focused on the loss of lean body mass and muscle wasting. We know today that women lose more fat than lean body mass. Substantial depletion of lean body mass does occur, however, in women with advanced HIV disease who have a body weight less than 90% of ideal weight. HIV wasting differs from simple starvation'in which most of the weight loss consists of fat. Wasting is an AIDS-defining condition and can be serious if it goes untreated, and significant weight loss in people living with HIV leads to greater risk of further complications and even death. Its Causes & Symptoms Although the exact cause of wasting is not yet known, many factors may contribute to it, including low food intake, poor nutrient absorption, a change in metabolism, and HIV-related infections. Low Food Intake. Loss of appetite occurs frequently with HIV. Some therapies have to be taken on an empty stomach or with a meal. It can be challenging for some people to eat when they're not hungry. Medication side effects such as nausea, changes in sense of taste, or tingling around the mouth also decrease appetite. Opportunistic infections in the mouth or throat can make it painful to eat. And infections in the gut can make people feel full after eating just a little food. Poor Nutrient Absorption. Healthy people absorb nutrients through the small intestine. In someone with HIV, this area can become infected, leading to difficulties with the absorption process. Diarrhea, a frequent side effect of HIV therapies, will often result in a loss of calories and nutrients. Altered Metabolism. HIV disease also affects food processing and protein building. There is increased activity of the immune system. People with HIV may need to take in more calories just to maintain their body weight. The virus seems to change some hormone levels, which can also affect metabolism. And HIVers have very high levels of certain types of cytokines, which produce inflammation to help the body fight infections. People with wasting may notice that they are unintentionally losing weight and feel as though they have less energy. They may also experience an involuntary loss of lean body mass, which includes muscles and organ tissue. Tackling It Wasting is generally treated by addressing each of its causes. Reducing Nausea and Vomiting. Reduced caloric intake among HIVers is often the result of a loss of appetite, frequently because of nausea. A number of agents to enhance dietary intake have been evaluated in National Institute of Allergy and Infectious Diseases clinical trials. Nutritional supplements also have a role in boosting caloric intake and are being assessed in NIAID's clinical trials research network. Appetite stimulants can also help improve food intake. Treating Intestinal Problems. Putting a stop to diarrhea and opportunistic infections in the intestines helps alleviate poor nutrient absorption. There has been progress in this area, yet some infections remain difficult to treat. Nutritional supplements that have been specifically designed to provide easy-to-absorb nutrients may also help the condition. Treating Changes in Metabolism. Growth hormone has been shown to increase lean body mass and weight in patients who have experienced involuntary weight loss as a result of HIV wasting. Future Outlook Wasting remains an issue for many HIVers, but with a proper treatment regimen it may be possible for them to bring the condition under control, just as Duran has. Throughout his career as an attorney and public servant, Duran has worked to defend human rights, providing legal counsel to ACT UP in the late 1980s, serving as the trial attorney for Los Angeles's needle-exchange programs, and defending the First Amendment rights of numerous protesters. 'Because I'm able to proactively manage my illness and associated conditions such as HIV wasting,' Duran says, 'I'm able to focus on what is most important to me--my life, my job, my community, and my family. I encourage others with this problem to talk to their doctors to seek treatment.' Lanier is a treatment advocate at the AIDS Service Center in Pasadena, Calif.