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Expected
Clinical Outcomes and Conclusions
Clinical
Outcomes
Patients who
meet the definition of HIV-associated wasting can expect a number
of beneficial clinical outcomes from therapy. These include the
following:
› Replacement
of lost body cell mass and weight;
› Improved physical capabilities and quality of life;
› Improved physical appearance;
› Decreased frequency of opportunistic infections, hospitalizations,
and related complications; and
› Improved survival.
Conclusions
HIV-associated
wasting remains an important complication in patients receiving
highly active antiretroviral therapy. The use of HAART, however,
does not eliminate HIV-wasting. Clinicians must pay careful attention
to changes in body weight, body cell mass, and body habitus in order
to accurately diagnose and manage this condition. This includes
examining the patient undressed and utilizing body composition analysis
on a regular basis.
Early and aggressive
intervention is required in patients who display depletion of body
cell mass. Clinicians need to utilize the expert consultation of
a dietitian or nutritionist who is experienced with this patient
population. Ongoing evaluation is critical once therapy is initiated.
Management
strategies for all patients with HIV-associated wasting must be
implemented concurrently. These strategies consist of controlling
viral load, maximizing immune competence, correcting any immediate
causes of wasting, addressing any psychosocial issues, improving
nutritional intake, and treating anorexia. If wasting still persists
after these interventions have been implemented, specific therapies
may then be undertaken. These include testosterone replacement therapy
in patients who are hypogonadal and the use of anabolic agents,
including recombinant human growth hormone in non-hypogonadal men
and women. Treatment with growth hormone results in increases in
lean body mass and improved survival in patients with HIV-associated
wasting. Other strategies, such as progressive resistance exercise,
should be tried on an individual basis. At the moment, optimal evidenced-based
algorithms for treating HIV-associated wasting have not been established.
Future directions
for research need to center on the following questions:
› What
is the best monotherapy or combination anabolic agent therapy (i.e.,
"wasting cocktail"?)
› What is the role of maintenance therapy and re-treatment?
› What are the stages of wasting?
› Can therapy be tailored to a specific stage?
› What is the cost-effectiveness of various therapies
and interventions?
› What are the long-term safety issues of these therapies?
Clearly, additional
studies will be required to answer these important questions. In
the meantime, clinicians and payers need to work together in order
to maximize the availability and reimbursement of treatment options
for patients with HIV-associated wasting. It is the hope of the
Consensus Development Panel that this document will provide the
necessary information so that payers can make informed decisions
regarding treatments for HIV-associated wasting and work effectively
with clinicians treating these patients.
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