
The management of a person with weight loss should
involve a number of steps: first, diagnosis and treat-
ment of any underlying opportunistic infections,
second, control of any symptoms that may have an
impact on food intake; and third, dietary advice.
0044 In the first instance dietary advice should be to
maximize food intake by making alterations in the
type and timing of meals, including well-chosen
snacks between meals, and possibly modifying exist-
ing foods to increase their energy and protein content.
This approach is a basic tool of dietetics that has
received little research attention. A small uncon-
trolled study in 34 people with HIV demonstrated
that dietary advice was associated with significant
improvements in nutrient intake, weight, and anthro-
pometric indices. A recent randomized controlled
study of dietary counseling with or without oral nu-
tritional supplements showed that nutritional coun-
seling can achieve a substantial increase in nutrient
intake in 50% of malnourished people with HIV
which after 6 weeks was not associated with changes
in weight and nutritional status.
0045 A second line of dietary intervention is the use of
specialized proprietary food supplements in combin-
ation with a balanced food intake. These usually take
the form of prepacked drinks that are nutrient-dense
and nutritionally complete. Since the appearance of
these products 12–15 years ago, they have acquired
the reputation of being able to promote weight gain in
a person who is losing weight. A systematic review of
energy-dense supplements in illness-related malnutri-
tion has demonstrated significant benefits to weight
and nutritional status but the effects on morbidity
and mortality are less clear. A small number of studies
have looked at the use of oral nutritional supplements
in people with HIV and demonstrated short-term
benefits to nutritional intake, weight, and nutritional
status. More studies are needed to clarify the role of
nutritional intervention in HIV-related weight loss
and particularly the effects on morbidity, mortality,
and clinical outcome.
0046 If adequate nutrition cannot be achieved orally,
then enteral or parenteral nutrition should be con-
sidered. The major indication for nutritional support
in HIV is the failure to maintain body weight. The
main goals of nutritional support are to improve
survival morbidity by reducing the complication rate
associated with secondary infections and to improve
quality of life. There are a small number of studies
that have looked at the efficacy of nutritional support
in HIV. In general they have concentrated on the
safety and on the ability to replenish lean body
mass. Reports of rates of infection vary considerably
with enteral and parenteral feeding but the general
conclusions are that nutritional support can be
provided with safety in people with HIV infection
but should be undertaken with caution because of
the serious risk of infection. A small number of
studies have looked at the ability to replenish lean
body mass using enteral and parenteral nutrition.
The results suggest that nutritional support can effect-
ively maintain body composition and reverse the
depletion of fat and lean tissue in patients with weight
loss in the absence of concurrent infection or when
provided in conjunction with effective treatment of
an infection. In the stressed catabolic patient with
systemic infection, malnutrition is not restored
towards normal with nutritional support and weight
gains tend to be mainly fat and not lean body mass. It
is important to note that in some studies the provision
of artificial feeding led to prolonged survival with
improved functional capacity and resumption of
employment – benefits which should not be over-
looked when considering the initiation of nutritional
support.
0047The provision of nutritional support in the terminal
stages of disease is a controversial issue. One study
demonstrated benefits to quality of life associated
with the provision of parenteral feeding in the ter-
minal stages of illness. Recently, studies of the effects
on survival of enteral and parenteral feeding have
underscored the importance of starting feeding before
it is too late.
0048The area currently receiving the most interest in
relation to nutrition and HIV infection is the use of
growth hormone and anabolic steroids for their
ability to replenish lean body mass. Testosterone
and testosterone analogs and recombinant human
growth hormone have been demonstrated to replen-
ish lean body mass effectively in people with 5–15%
weight loss. Benefits have been demonstrated with
and without supervised exercise programs. This is a
relatively new area of nutrition and the potential role
of anabolic therapies in conjunction with the provi-
sion of nutritional support raises many questions:
.
0049Does increasing lean body mass change the prog-
nosis?
.
0050Is long-term anabolic steroid use safe?
.
0051Which patients are likely to benefit – those with
mild or advanced disease?
.
0052Should steroids be used intermittently or continu-
ously?
.
0053Which anabolic drug is most effective?
Advances in the understanding of the pathophysiol-
ogy of weight loss wasting have led to a greater
understanding of the role of nutrition in HIV infec-
tion. The primary determinant of weight loss is fre-
quently reduced food intake but this cannot alone
explain all aspects of HIV-associated wasting and
3118 HIV DISEASE AND NUTRITION