This month, Robert Keller, MD, a physician and immunologist with a large HIV practice in Hollywood, Florida, discusses Marlene Diaz’s recent experience with illness and weight loss—and the lessons to be learned by other PWAs.

Marlene became quite sick in late October, with a severe cough and fever that lasted for several weeks. (Two weeks into the illness, after switching antibiotics, her respiratory infection began to resolve.) The combination of illness and antibiotic side effects left her nauseated and repulsed by food, and her weight dropped from her normal 130 pounds down to 116. During this time, she also had a day of severe vaginal bleeding (a week after her period), followed by several days of spotting—the cause never diagnosed. By mid-November, she felt weak, fatigued and depressed, with visible wasting in her face, arms and calves. A brief course of the drug Megace didn’t restore her appetite, but over time she forced herself to eat more, and drank a daily calorie-boosting protein shake. By mid-December, she finally felt well enough to return to work, although her energy still lagged, the weakness and loss of muscle tissue remained, and her weight was still down at 120.

Unfortunately, this scenario isn’t surprising. Anyone with fever can be in trouble after only a week. It lowers appetite and raises metabolism, burning up calories much faster, which causes weight to drop rapidly. In my practice, if illness continues for more than a week, we do a bioelectrical impedance analysis (BIA)—a quick, painless electrical test—to check for wasting, as well as a complete blood count (CBC) and a blood chemistry. I have all my patients do these tests quarterly so we have a baseline for comparison. For as long as the illness continues, we bring patients back weekly for followup blood work and, if they’re not regaining weight, BIAs.

The BIA reading of the body cell mass (BCM)—that life-sustaining tissue found in your muscles and organs—often decreases after as little as a week of illness, revealing the urgency of intervention to prevent a slide into serious wasting, a major killer of PWAs. With Marlene, we don’t know if this decrease in BCM occurred, since her most recent BIA wasn’t done until she had regained much of her lost weight. And her only previous BIA, done a year earlier, wouldn’t have been a good basis for comparison.

Marlene’s muscle weakness indicates that she was probably burning up muscle tissue during this illness, and her worst-point weight loss of more than 10 percent of her body weight qualified her for a wasting diagnosis at that time. Although her mid-October blood chemistry showed little amiss, I am concerned that her bleeding incident might have led to anemia—possibly explaining her continuing weakness and fatigue. Running a new CBC would be important to diagnose this.

For patients experiencing this combination of prolonged illness and weight loss, I recommend a number of immediate interventions:

  • DEFATTED WHEY POWDER to keep up protein and glutathione, a key antioxidant that counters the drastic oxidative stress caused by HIV and worsened by other infections (especially when fever is present). For a high-calorie drink, blend it with a banana, milk (soy or rice milk if there’s lactose intolerance), and MCT oil (a safe fat), along with other fruit for flavor. (I never recommend such sugar-laden supplemental drinks as Ensure, Sustacal, Resource and Enercal.)
  • INCREASED VITAMIN AND MINERAL SUPPLEMENTATION to make up for micronutrient deficiencies created by lack of food intake.
  • OXANDROLONE (OXANDRIN), an oral anabolic steroid, to stimulate appetite and muscle growth. Two other possible hunger-boosters: the drug DRONABINOL (MARINOL) and—according to reports from some of my patients— MARIJUANA (although I can’t actually recommend it).
  • ACIDOPHILUS. I believe that all PWAs have inadequate good bacteria in their gastrointestinal tract, so all my patients take acidophilus. Since taking antibiotics worsens the problem, I recommend doubling the dose while on such drugs.
  • FEVER-REDUCING MEDICATION to help prevent weight loss. I’d usually recommend aspirin, but since Marlene was hemmorhaging I’d probably suggest Tylenol, normally avoided since it reduces glutathione; hopefully, taking glutathione-boosting nutrients would counter that.
  • COUGH-SUPPRESSANT MEDICATION, especially at night—eight hours of sleep is a must for recovery from illness. I’d recommend Robitussin; if it doesn’t work, Tessalon perles (a non-narcotic cough-suppressant).

After two weeks of all of the above, if weight is not coming back and BCM is still too low, I recommend substituting human growth hormone (Serostim) for the oxandrolone. It should be continued until both weight and BCM have returned to normal. Boosting the body back toward health with all these treatments is vital to prevent a potentially fatal downhill slide toward wasting. And to lessen suffering and disability, the time to intervene is when the illness begins.