HAART improves survival in HIV-positive patients with wasting syndrome

HIV-positive patients diagnosed with wasting syndrome are more likely to survive if they have a CD4 cell count above 200 cells/mm³ and receive anti-HIV therapy with at least two antiretroviral drugs, according to a US study published in the June 1^st edition of the Journal of Acquired Immune Deficiency Syndromes.

Although these findings may hardly appear startling, the investigators say that this is the first study to show improved survival for people diagnosed with wasting since the introduction of HAART.

The investigators used the Center for Disease Control definition of wasting syndrome. This states that wasting syndrome is an AIDS-defining condition, characterised by involuntary loss of 10% of body weight plus either chronic diarrhoea lasting for at least 30 days, or chronic weakness and fever in the absence of another infection (other than HIV) or malignancy capable of causing severe weight loss.

In an observational study involving over 42,000 HIV patients from eleven treatment centers in the US, investigators from the Centers for Disease Control and Surveillance monitored trends in the incidence of wasting syndrome from 1992 to 1999, the influence of a wasting syndrome diagnosis on the subsequent incidence of HIV-related opportunistic infections, and to see what factors were associated with improved survival in patients with wasting syndrome.

A total of 3,289 cases of wasting syndrome were identified by the investigators. The incidence of the syndrome declined over time, from 30.2 cases per 1000 person-years of follow-up in 1992 to 11.9 cases per 1000 person-years in 1999.

There was a high incidence of AIDS-defining and HIV-related opportunistic infections present either at the time wasting syndrome was diagnosed, or in the period following its diagnosis, with CMV, PCP and MAI being common. Factors associated with poorer survival following a diagnosis of wasting syndrome included PCP (OR=1.5 95% CI 1.3 – 1.7, p=<.001 and="" ci="" mai="" p="" toxoplasmosis="">

Patients were more likely to survive if they had a nadir CD4 cell count above 200 cells/mm³ when wasting syndrome was diagnosed (OR=0.2 95% CI 0.2 –0.3, p=.001), were aged less than 50 years (OR=0.8 95% CI 0.7 – 0.9, p=.002), received treatment with at least two antiretroviral drugs (OR=0.7 95% CI 0.6-0.8, pMegace were not associated with improved survival.

Survival also improved with the introduction of HAART in 1996.

For 191 patients, information on height and weight was also available, and for this sub-set of patients a body mass index of greater than 20 was found to be a predictor of survival.

The investigators note a falling incidence of wasting syndrome throughout the 1990s, with a marked reduction in its frequency after the introduction of HAART. They suggest that the declining incidence of wasting syndrome prior to 1995/96 could have been due to the increased availability of antiretrovirals and expanded use of prophylaxis against opportunistic infections.

Survival improved further during the HAART era, resulting from the use of combinations of antiretrovirals. The investigators emphasise, “these findings are new; previously it was reported that HAART had not been shown to be associated with weight gain or viral load to correlate with body weight changes.”

The investigators also found a non-significant link between the use of oxandrolone and survival. However, they note that their study was observational and therefore they could not rule out the existence of other factors improving survival in these patients.

Although the investigators suggest that the findings of their study are reliable, they suggest that they are treated with caution and should be confirmed with clinical trials “because of the inherent limitations of surveillance data to address associations between treatment and clinical outcomes.”

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