The loss of fat and lean body mass known as wasting syndrome was still a problem in 2018, with nearly one in five people living with HIV having evidence of the syndrome, according to a study of health claims data published in the journal AIDS.

The prevalence of wasting syndrome was much higher in HIV-positive people who received health coverage through Medicaid and it was slightly elevated among Black folks. However, the authors found no association between wasting and modern HIV medications.

Severe wasting syndrome was a hallmark of the early AIDS epidemic, when HIV-related metabolic changes and opportunistic infections resulted in people losing 10% or more of their body mass. What’s more, some early antiretrovirals were associated with a combination of peripheral fat loss and abdominal fat gain known as lipodystrophy. Today, while wasting is difficult to reverse, it can be limited by starting HIV medication as soon as possible.

Javeed Siddiqui, MD, MPH, of the telehealth company TeleMed2U, and colleagues culled through national medical and pharmacy claims data from 2012 to 2018 for codes related to HIV diagnosis, antiretroviral medications, weight loss and appetite stimulation. They excluded people with a cancer diagnosis, which can also lead to wasting.

During those years, Siddiqui and colleagues identified 42,587 adults diagnosed with HIV. Nearly two thirds were men, more than 70% were Black, 68% received care through Medicaid and 64% were taking HIV medications. The study didn’t report which specific antiretrovirals people were using.

While the study showed that 18% of charts showed evidence of HIV-associated wasting, that did not differ significantly between people taking HIV meds and those who were not.

What was different was the likelihood of wasting among people receiving care through the Medicaid (public insurance for low-income people) and those covered by private insurance or Medicare (public coverage for seniors). While just 8% of people with private insurance or Medicare met criteria for wasting, nearly one in four people (24%) receiving care through Medicaid had wasting syndrome. Overall, people using Medicaid were 71% more likely to have wasting syndrome. The study also found that people using Medicaid were less likely than those with private insurance or Medicare to be taking HIV medications (44% versus 19% untreated).

While still making up a majority of people with wasting syndrome, men were underrepresented in the wasting group compared with the overall study population (62% versus 66%). And people with wasting were a median of two years older, at 46 years, than the cohort as a whole.

Unsurprisingly, people with opportunistic infections such thrush, shingles or Pneumocystis pneumonia were also more likely to have wasting syndrome. For instance, 64% of those with at least one opportunistic infection experienced wasting, compared to 39% of those without. People with wasting syndrome were also more likely to have high blood cholesterol and other metabolic abnormalities including lipodystrophy. And people were three times more likely to have wasting syndrome if they had been hospitalized at least once since their HIV diagnosis.

Nearly three quarters of people with wasting syndrome were Black—a rate roughly proportionate to those in the group as a whole. However, being Black was still associated with a 10% increased risk of wasting.

“Medicaid is the largest source of insurance coverage for PWH [people with HIV],” wrote the study authors. “These data suggest the need to monitor for unintentional weight loss in PWH, understand the complex and multifactorial etiologies of HIVAW [HIV-associated wasting], and evaluate the risk of HIVAW by comorbidities and payer type. As the population of PWH continues to age, the risk of developing frailty (which includes weight loss) will be another important health assessment for this vulnerable population.”

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