Systemic Conditions Related to HIV/AIDS
In addition to HIV-related infections and cancers, there are a number of other conditions that can affect patients who have HIV/AIDS. These disorders are generally referred to as "systemic conditions."
Antiretroviral therapy can help prevent many AIDS-related systemic conditions, including wasting syndrome, generalized lymphadenopathy, low blood count, and HIV-related gall bladder disease. If antiretrovirals do not prevent the onset of illness, or if the patient starts therapy after a condition has already developed, antiretroviral drugs make the condition much easier to treat.
A few HIV-related systemic conditions, such as lipodystrophy (abnormal metabolism of fat), elevated cholesterol, and possibly diabetes, are actually more common with, and may even be caused by antiretroviral therapy.
HIV/AIDS & Lipodystrophy
Lipodystrophy is an abnormal distribution of body fat that occurs in patients who are on antiretroviral therapy. Patients taking antiretrovirals tend to lose fat on the arms, legs, buttocks, and face, and tend to accumulate fat around the belly and breasts. Some patients develop a fat lump on the back of the neck, which is called a "buffalo hump." Scattered lumps of fat that form under the skin are called lipomas.
It is estimated that 575% of patients taking antiretroviral drugs develop lipodystrophy. The exact cause of lipodystrophy is unknown. Initially, it was thought to be a side effect of protease inhibitors. Protease inhibitors may increase the speed at which this condition develops, but lipodystrophy also occurs in patients who do not take protease inhibitors. Risk factors include age, length of antiretroviral therapy (nucleosides in particular), race, and baseline level of fat.
Lipodystrophy is generally not a serious condition. Possible complications include an increased risk for heart disease, breast pain, headaches, and difficulty sleeping and breathing caused by "buffalo humps." Lipodystrophy often causes psychological and emotional problems and some patients stop taking antiretrovirals because they are so disconcerted with the way their body is changing.
Treatment for lipodystrophy includes exercise, low fat diet, anabolic steroids, growth hormone, and alteration of antiretroviral therapy. Patients who want to change their antiretroviral therapy should do so only under the strict supervision of an HIV specialist.
Recent studies have shown that as many as two-thirds of HIV patients in the United States are overweight or obese. The success of antiretroviral therapy, combined with unhealthy eating and exercise habits may contribute to obesity in patients with HIV.
HIV/AIDS & Hyperlipidemia (high levels of lipids in the blood)
Hyperlipidemia refers to elevated blood levels of cholesterol and triglyceride that occur in patients who are on antiretroviral therapy. Hyperlipidemia is a significant risk factor for the development of cardiovascular disease. Elevations in cholesterol and triglyceride levels may occur in patients who are taking protease inhibitors and non-nucleoside drugs.
To reduce the risk for heart disease, initial efforts to control hyperlipidemia through diet, exercise, and other lifestyle changes should be made. Medications can also be used to reduce hyperlipidemia to normal blood levels. Patients who have hyperlipidemia should consult with their physician, a nutritionist, or other health care provider about how to reduce cholesterol levels.
HIV/AIDS & Diabetes
Diabetes was first attributed to antiretroviral therapy in 1996. Antiretrovirals may trigger an earlier onset in patients who would have developed diabetes at a later time. Some studies indicate that the incidence of diabetes in patients who are on antiretrovirals is about the same as in the HIV-negative population. Everyone, whether HIV-positive or not, should be screened periodically for diabetes.
HIV/AIDS & Generalized Lymphadenopathy
Generalized lymphadenopathy, also known as persistent generalized lymphadenopathy (PGL), is swelling of the lymph nodes throughout the body (e.g., neck, groin, armpits). This condition is caused by the body's reaction to untreated HIV infection and may be a symptom of Hodgkin's lymphoma, NHL, or another HIV-related infection or cancer. PGL is rare in patients who are on antiretroviral therapy. Persistently swollen glands should be evaluated by an HIV/AIDS specialist.
HIV/AIDS & Low Blood Count
Low blood count refers to inadequate numbers of red blood cells (anemia), white blood cells (leukopenia), and platelets (thrombocytopenia). Patients can have low levels of one, two, or all three types of cells. Antiretroviral therapy usually reverses these conditions, although certain antiretroviral medications can contribute to low blood count.
Anemia is one of the most common blood abnormalities in patients with HIV/AIDS. Symptoms include fatigue, shortness of breath, and lightheadedness. Studies show that patients who have HIV/AIDS and develop anemia experience a decreased quality of life and an increased risk for death.
A number of factors can cause low blood count, including the following:
- HIV can infect the bone marrow (where the blood cells are made) and affect cell production
- Hormone deficiencies
- HIV-related infections or cancers
- Nutritional deficiencies
- Some antiretroviral drugs
Treating low blood count depends on the type and its cause. For example, anemia is caused by a Vitamin B12 deficiency and replacing the vitamin or supplementing the diet usually is an effective treatment.
HIV/AIDS & HIV-related Gall Bladder Disease
The gall bladder is a small, pear-shaped organ located under the liver. The main function of the gall bladder is the storage of bile (substance made by the liver). Gallstones are pebble-like formations of bile that accumulate and block the flow of bile from the gall bladder, leading to infection. Gallstones are common in adults, whether HIV-positive or not.
Most patients with gallstones are nauseated and experience pain in the right upper part of the stomach (especially after eating fatty foods), but the condition may be asymptomatic. Pain also may occur in the upper middle part of the belly and radiate to the back or shoulder blades.
In addition to gallstones, various HIV-opportunistic infectious agents, including yeast, cryptosporidiosis, and cytomegalovirus, can infect the gall bladder and surrounding tissues. These infections cause symptoms similar to gallstones, but upon examination, there are no gallstones.
Patients who have HIV/AIDS and develop symptoms of gall bladder disease should see a health care provider experienced in the evaluation of abdominal pain in HIV-positive patients. Treatment for HIV-related gall bladder disease involves removing the gall bladder.
Wasting syndrome is involuntary weight loss greater than 10% of body weight, accompanied by more than 30 days of diarrhea, weakness, or fever. This condition was one of the first noted HIV-related systemic conditions and, before antiretrovirals, was one of the most common HIV-related conditions.
Patients with wasting are more likely to develop an HIV-related infection or cancer and are more likely to die from AIDS. In particular, weight loss of 3% in one month, 5% in 6 months, or 10% in 12 months often indicates the development of HIV related illnesses.
HIV infection affects the body in many ways. An increased demand for calories compounded by a poor intake of calories, results in weight loss and poor nutrition:
- Altered metabolism—Baseline metabolism is the rate at which the body burns calories. HIV infection (without illness) increases the baseline metabolism by 10%, meaning that a patient with HIV needs more calories to maintain body weight. In an HIV-infected patient who has an infection or cancer, the baseline metabolism increases by about 30%, requiring even more calories to maintain a normal body weight.
- Low food intake—Many patients with HIV, especially those who have an HIV-related infection or cancer, do not eat enough food to maintain body weight. They may have a poor appetite or may not eat when they are hungry because so many AIDS drugs must be taken on an empty stomach. In addition, opportunistic infections in the mouth may make it difficult to eat, infections in the intestines may make eating unpleasant, or patients may not have the energy to prepare food.
- Poor nutrient absorption—In healthy people, nutrients are absorbed from food in the small intestine. In patients who have HIV, nutrients are not well absorbed because of intestinal infections, diarrhea, and perhaps, the virus itself.
- Hormonal and biochemical changes—Most of the weight lost in HIV wasting is lean body mass, the body's working tissue of the body (e.g., muscle). Normally, a person with poor nutrition and a high metabolism burns off fat first and then muscle. Due to hormonal and biochemical changes, patients with HIV tend to burn off muscle first and then fat. For example, patients with HIV have low levels of testosterone, which is a hormone that helps maintain lean body mass.
Antiretroviral therapy and treatment for HIV-related infections or cancers decreases the metabolism. A decreased metabolic rate means that calories are not used up as quickly and weight loss is slowed. Good nutrition is essential. Patients who experience wasting may benefit from a nutritionist.
Several medications are used to treat wasting by increasing the patient's appetite, lean body mass, or body fat, either singly, or in combination. Medications include the following:
- Megesterol acetate was the first medication approved by the Food and Drug Administration (FDA) to treat wasting. This drug is a powerful appetite stimulant. It reduces testosterone levels in men and women and the weight gained is primarily fat.
- Dronabinol, an active ingredient in marijuana, is an appetite stimulant and does not have a direct effect on fat or muscle.
- Human growth hormone (HGH) increases appetite and lean body mass.
- Thalidomide increases appetite, lean body mass, and fat.
- Steroids (e.g., oxandralone, nandralone, testosterone) increase appetite and a sense of well-being. Weight gained is predominantly lean body mass.