HIV This Week

Willard S, Holzemer WL, Wantland DJ, Cuca YP, Kirksey KM, Portillo CJ, Corless IB, Rivero-Méndez M, Rosa ME, Nicholas PK, Hamilton MJ, Sefcik E, Kemppainen J, Canaval G, Robinson L, Moezzi S, Human S, Arudo J, Eller LS, Bunch E, Dole PJ, Coleman C, Nokes K, Reynolds NR, Tsai YF, Maryland M, Voss J, Lindgren T. Does “asymptomatic” mean without symptoms for those living with HIV infection? AIDS Care. 2009;21(3):322-8.

Throughout the history of the HIV epidemic, HIV-positive patients with relatively high CD4 counts and no clinical features of opportunistic infections have been classified as “asymptomatic” by definition and treatment guidelines. This classification, however, does not take into consideration the array of symptoms that an HIV-positive person can experience long before progressing to AIDS. This short report describes two international multi-site studies conducted in 2003-2005 and 2005-2007. The results from the studies show that HIV-positive people may experience symptoms throughout the trajectory of their disease, regardless of CD4 count or classification. Providers should discuss symptoms and symptom management with their clients at all stages of the disease.

Editors’ note: Both physical and psychological symptoms were reported by ‘asymptomatic’ people living with HIV regardless of CD4 count category or whether they were on antiretroviral medications. The twenty most frequently reported symptoms in the 33 to 60% range included fatigue (57-60%), depression, muscle aches, weakness, thirst, worry, difficulty concentrating, memory loss, dry mouth, insomnia, joint pain, diarrhoea, shortness of breath with activity, night sweats, gas/bloating, headaches, abdominal pain, and numbness/tingling of hands/fingers or feet/toes or legs (33 to 37%). Recognising both the broad variation in how patients perceive and rate their symptom experience and that many of these symptoms in HIV-positive individuals can be addressed by specific measures just as they can be in HIV-negative people, clinicians need to carefully interview their ‘asymptomatic’ patients for the presence of symptoms and address symptom management to improve quality of life.

Madec Y, Szumilin E, Genevier C, Ferradini L, Balkan S, Pujades M, Fontanet A. Weight gain at 3 months of antiretroviral therapy is strongly associated with survival: evidence from two developing countries. AIDS. 2009;27(7):853-61.

In developing countries, access to laboratory tests remains limited, and the use of simple tools such as weight to monitor HIV-infected patients treated with antiretroviral therapy should be evaluated. Madec and colleagues conducted a cohort study of 2451 Cambodian and 2618 Kenyan adults who initiated antiretroviral therapy between 2001 and 2007. The prognostic value of weight gain at 3 months of antiretroviral therapy on 3-6 months mortality, and at 6 months on 6-12 months mortality, was investigated using Poisson regression. Mortality rates [95% confidence interval (CI)] between 3 and 6 months of antiretroviral therapy were 9.9 (7.6-12.7) and 13.5 (11.0-16.7) per 100 person-years in Cambodia and Kenya, respectively. At 3 months, among patients with initial body mass index less than or equal to 18.5 kg/m (43% of the study population), mortality rate ratios (95% CI) were 6.3 (3.0-13.1) and 3.4 (1.4-8.3) for those with weight gain less than or equal to 5 and 5-10%, respectively, compared with those with weight gain of more than 10%. At 6 months, weight gain was also predictive of subsequent mortality: mortality rate ratio (95% CI) was 7.3 (4.0-13.3) for those with weight gain less than or equal to 5% compared with those with weight gain of more than 10%. Weight gain at 3 months is strongly associated with survival. Poor compliance or undiagnosed opportunistic infections should be investigated in patients with initial body mass index less than or equal to 18.5 and achieving weight gain less than or equal to 10%.

Editors’ note: While CD4+ count and viral load remain the gold standards for monitoring patients on antiretroviral treatment, simple tools such as weight gain at 3 months can alert providers to the need to assess adherence, the presence of an opportunistic infection such as tuberculosis, or poor nutritional intake. Whereas overall programme performance can be measured by the proportion of patients achieving at least 10% weight gain at 6 months, the 3-month point is more critical for patient evaluation. As this study of over 5000 Cambodians and Kenyans initiating antiretroviral treatment shows, there was a 6-fold increase in risk of dying for patients with less than or equal to 5% weight gain compared to those with more than 10% weight gain at 3 months. CD4 count at treatment initiation was no longer predictive of mortality between 3 and 6 months once weight gain at 3 months was taken into account. Until antiretroviral treatment is more widely available so that patients initiate treatment at an earlier stage of infection, simple, low-cost weight monitoring will be particularly relevant.