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Physician’s Weekly spoke with Daniel Lee, MD, about his work on an expert panel that redefined HIV-associated weight loss in virologically suppressed patients.

“[HIV-associated wasting (HIVAW)] now occurs mostly among virologically suppressed PWH, but the underlying mechanisms, although both related to persistent viral infection, are not exactly the same,” researchers wrote in Clinical Infectious Diseases. “A subgroup of [people with HIV] receiving modern ART continue to unintentionally lose weight despite virologic suppression. Reports suggested that [people with HIV] who experience this type of weight loss experience a greater number of hospitalizations and emergency department visits, have significant declines in quality of life, incur 1.3 times higher healthcare costs, and can be 3 times more likely to die than people without such weight loss.”

Due to the prevalence of predominantly sustained weight loss among patients with well-controlled HIV, “this contemporary presentation of HIVAW has been redefined as HIV-associated weight loss (HAWL),” Daniel Lee, MD, and colleagues wrote.

As a result, awareness of this concept is necessary to understand underlying pathogenic mechanisms and risk factors.

Physician’s Weekly (PW) spoke with Dr. Lee to learn more about the new description of unintentional weight loss in patients with HIV.

PW: Can you tell us about the context of your consensus paper?

Daniel Lee, MD: I was asked to be part of an expert panel convened to re-evaluate the concept of HIV-associated wasting. The old CDC definition, from the 1980s, was based on AIDS-related wasting, where people were not on ART that was working well and there was severe wasting. An updated definition has never been developed within this current era of newer ART. Clinically, though, I still see people who are losing weight, but not in the classic way. That’s why we aimed to get this consensus.

How did you and your colleagues form a consensus?

As with any consensus statement, it involves collating agreed-upon information. We ended up with a good consensus statement on what HIV-related weight loss looks like. Though we don’t see much weight loss in recent years because of ART, untreated HIV leads to increased cytokine activity and inflammation, speeding up metabolism and leading to weight loss. The thought most people have is that, by starting HIV medication, you reverse that process. But the reality is that some people still have issues with weight loss that cannot be explained but are perhaps related to HIV.

We moved away from the word “wasting.” When older HIV clinicians think of wasting, they think of people dying. When I ask them if they see wasting, they say no, but only because we don’t see people dying anymore. There are people losing weight, but because they don’t fit that older picture of severe wasting, people think it doesn’t exist anymore. This new terminology is meant to help older clinicians consider this entity of weight loss, even in people whose disease is well-controlled, and introduce the concept to younger doctors.

Why is it so important to recognize this?

There are people whose HIV is well-controlled who still have higher levels of inflammatory markers. Inflammation is what drives all end-organ diseases. It’s not unusual to see people with HIV who seem to be aging a bit quicker, with some estimates putting patients up to even 10 or 15 years older than their biological age. You have to consider frailty in these patients.

Our definition of HAWL tries to exclude the typical reasons people might lose weight. In some patients with HIV, there are issues with food insecurity. We still see things like poor appetite, poor diet, and sometimes mental health issues. We also need to rule out things like opportunistic infections or malignancy. Sometimes, there are gastrointestinal issues or endocrine disorders. We don’t yet understand why a small subset of people still lose weight without any of these other conditions.

Is there anything else you’d like to mention?

Ours is a comprehensive review, and we do talk about treatment. If you look at papers about HIV-associated wasting, it’s mostly older studies. There have only been a few more recent papers. But I think this is a good summary. It goes through how things have evolved, goes through incidence and prevalence data, and then talks about how you screen for HAWL, how you manage it, and how you treat it.