Metabolic and Nutritional Aspects of HIV Infection in the Era of HAART

With the advent of highly active antiretroviral therapy (HAART), AIDS-related wasting has become a less prevalent problem. However, issues related to nutrition and body composition have clearly not disappeared. In recent months, researchers and clinicians have reported a variety of metabolic abnormalities in persons on HAART . At first came reports of diabetes in persons on protease inhibitor therapy. This was followed by reports of abnormal accumulations of fatty tissue at the back of the neck, termed buffalo humps. Persons living with HIV infection and their care providers also began to note changes in body fat distribution manifested by skinny arms, legs, buttocks, and cheeks with prominent fat accumulation in the abdomen and breast enlargement. This syndrome has been termed lipodystrophy (also known as "crix belly" or "protease paunch"). Attention has also turned recently to elevations in blood lipid levels in persons on HAART.

Much remains unknown about the prevalence of these metabolic abnormalities and their cause. Even less is known about how these problems should be managed medically. The long term consequences of abnormal fat distribution, high blood sugars, and elevated lipid levels are of concern because of the potential increased risk of atherosclerosis (hardening of the arteries) which could lead to heart attacks and strokes.

Clearly more research into these metabolic problems is of tremendous importance. Having recognized this need and not being encumbered with a bureaucracy, CRIA has quickly launched two studies that should provide important insights into the mechanism and management of two of these problems. Our study of glucose tolerance in persons initiating protease inhibitor therapy is well under way and has recently expanded to sites in Baltimore, Boston, and Philadelphia. We have also initiated one of the first studies of a possible treatment of lipodystrophy -- a 24 week trial of human growth hormone.

In fact, body composition and nutrition have been a focus of CRIA's research efforts for the past few years. This focus has been driven largely by the expertise provided by three members of our Board of Directors who are internationally renowned authorities in the field: Drs. Douglas Dieterich, Donald Kotler, and Judith Rabkin. When little emphasis was being placed on testing interventions for wasting, CRIA initiated and sponsored two studies, one comparing two nutritional supplements to prevent weight loss, and another looking at testosterone and/or Met-Rx® to treat weight loss. Results of the former study were presented at the 12th International Conference on AIDS in Geneva, and the latter study is still enrolling. Furthermore, CRIA has played a major role in studying oxandrolone, an anabolic steroid as a treatment for wasting in both men and women.

This issue of CRIA Update is devoted to metabolic and nutritional aspects of HIV infection in the era of highly active antiretroviral therapy (HAART). We have assembled a group of writers to contribute their expertise in this field. Tim Horn, co-author of Treatment Action Group's (TAG) Wasting Report, has summarized the available data on body composition changes and current treatments for wasting. Since anabolic steroids are in wide use, they are the subject of a separate article by Nelson Vergel, who is a widely respected expert in the field and Director of Program for Wellness Restoration (PoWeR). Edwin Krales, MS, CDN, a nutritionist and Outreach Coordinator at the Momentum AIDS Project in New York, has contributed his talents in the area of practical dietary considerations for persons on combination antiretroviral therapy. We would also like to thank Dr. Donald Kotler who served as guest editor for this issue of CRIA Update.

While there are many unanswered questions posed in this issue, we hope that our research efforts and those of our colleagues elsewhere will shed further light on the complicated metabolic picture that is emerging in persons with HIV infection.

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