factors include: HIV that is untreated or unresponsive to treatment (the precombination therapy experience), opportunistic infections and tumor, malabsorption due to “AIDS enteropathy,” depression, gastrointestinal adverse reactions to antiretroviral agents or other treatments (including decreased intake and lipoatrophy), hypogonadism, protein energy dysmetabolism, and cytokine dysregulation (Mangili et al., 2006).

Outside of the HIV Infection Listings, weight loss due to any digestive disorder is described under Listings 5.08 and 105.08 in the Digestive System. Because of the increased risk of mortality and a potential impact on quality of life and functioning, the committee concludes that HIV wasting syndrome should be included in the HIV Infection Listings to the extent that they cover substantial involuntary weight loss that markedly impairs functioning.

Kaposi’s Sarcoma

In HIV-infected persons, Kaposi’s sarcoma (KS) is uniformly associated with coinfection with human herpesvirus-8 (HHV-8). KS is definitively diagnosed by biopsy, and histologically KS is characterized by vascular proliferation and a vigorous inflammatory reaction. In early stages, it is debated whether KS is a true malignancy, but this seems clearer in more advanced disease. It arises from endothelial tissues and can affect any region of the body except the central nervous system. KS is especially common in some body regions and organs. Areas commonly affected include the skin, the oral pharynx, the conjuctiva, and the gastrointestinal tract. Some patients have lymphatic obstruction with chronic leg edema. Lesions in the digestive system can occasionally bleed; involvement of the pulmonary parenchyma, often with associated pleural effusions, is symptomatic and rapidly fatal (see Chapter 4). Advanced Kaposi’s sarcoma in any region can cause death, although this is very uncommon with the availability of antiretroviral therapy, except when there is pulmonary involvement.

It is important to note that there is increased social stigma because the lesions are visible. The lesions can cause particular difficulty in the workplace for the person who has them. Additionally, larger lesions can cause chronic pain. For these reasons the committee specifically identified KS and not other opportunistic infections.

The risk of morbidity and mortality of Kaposi’s sarcoma has been reduced dramatically since the beginning of the epidemic, largely as a result of combination antiretroviral therapy (Bower et al., 2009; Grabar et al., 2008; Mocroft et al., 2004). In one study, the percentage of KS in HIV-infected Americans fell from 1980 to 1989 (63.9 percent) and from 1996 to 2002 (30 percent) (Engels et al., 2006). An 85 percent decline in risk of death was found between precombination antiretroviral therapy (1993 to 1995) and

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