Assessment Protocol for Patients with HIV-Associated Wasting

Initial Evaluation and Diagnosis

1. History and Physical Examination

During the initial evaluation of a patient for HIV-associated wasting, the clinician should perform a thorough and complete history and physical examination. The physical examination must be performed with the patient completely undressed. This way, the clinician can ascertain signs of wasting (abdominal, gluteal, and limb atrophy) that may be hidden by clothing. The physical examination should also rule out any concomitant infections or other medical problems.

During the intake history, the clinician should ask a variety of questions designed to determine an initial impression of the patient's nutritional status, caloric intake, appetite, and gastrointestinal and physiological functioning. Suggested questions may include the following:

› Have you noticed any weight loss?
› Has your appetite changed?
› Have you developed diarrhea?
› Are you feeling weaker and more fatigued than normal?
› Are you having trouble getting around performing daily activities?

Using the patient's answers to these questions, the clinician will be able to formulate a working diagnosis of HIV-associated wasting and its potential causes.

2. Body Composition Measurements

The following measurements should be taken and calculated related to body composition:

› Age
› Height
› Weight
› Ideal body weight
› Body cell mass (by BIA)
› Body mass index (BMI)

3. Laboratory Tests

The laboratory evaluation of the patient should include the following tests:

› Plasma HIV RNA
› CD4 cell count
› Serum testosterone (free and total)
› Serum albumin (as clinically warranted)
› Thyroid function tests (as clinically warranted)

4. Psychosocial Evaluation

During the initial evaluation of the patient, the clinician also needs to rule out any psychiatric disorders that might interfere with the patient's ability to eat. For example, anxiety and depression are known causes of anorexia. They are often present in patients with HIV infection. Feelings of anxiety or depression can escalate in the presence of opportunistic infections such as oral thrush, or in the presence of symptoms such as diarrhea.29 Functional status should also be assessed.30

5. Dietary Assessment

Optimally, all patients suspected of having HIV-associated wasting should be referred to a competent registered dietician or nutritionist who is experienced with these patients. Such a referral will refocus a patient's attention on eating properly and selecting the appropriate foods.31 The dietician should perform the following assessments on the patient:

› Evaluate intestinal function;
› Review food intake and caloric values; and
› Estimate physical activity level.

The clinician should maintain the relationship with the registered dietitian during subsequent patient visits and throughout the course of treatment.

Follow-Up Visit

Once all laboratory test results are completed and the evaluation by a registered dietitian has been conducted, the patient should return to the clinician for a follow-up visit. During this visit, the clinician should conduct the following activities with the patient:

› Review all laboratory test results;
› Discuss all current medications, including antiretroviral therapy;
› Readjust antiretroviral therapy, as required, based on laboratory evaluation;
› Provide follow-up for any identified medical or psychiatric problems;
› Review the registered dietitian's evaluation of the patient;
› Discuss therapeutic options for HIV-related wasting; and
› Initiate therapy if indicated.

Ongoing Subsequent Visits

Once treatment for HIV-associated wasting has been initiated, the patient should be scheduled for return visits with the clinician every three months or as directed by current symptoms. This is similar to the standard follow-up evaluation recommended for patients on HAART. At these subsequent visits, the clinician once again needs to perform many of the activities first conducted during the initial visit. These include the following:

› Perform an interval history and physical examination with the patient undressed;
› Measure serial body weights and body composition parameters (body cell mass) using bioelectrical impedance analysis (BIA);
› Monitor antiretroviral therapy and adjust as necessary;
› Assess any ongoing medical or psychiatric problems in consultation with outside specialists;
› Maintain patient's relationship with registered dietitian as needed; and
› Measure total and free testosterone on an annual basis or more often as clinically necessary.

It is important to note that the optimal treatment strategies for HIV wasting have not been established. Treatment should be individualized. Patients should be given all their options and allowed to make an informed choice. Selecting the best treatment option must also take into consideration the patient's previous compliance history, as well as the payer source. Clinicians are encouraged to work with the patient's insurance carrier in order to provide reimbursement professionals with ongoing education about this condition and the clinical rationale for recommended treatment options.