Introduction

Wasting is a common problem for people with AIDS and is defined as involuntary loss of more than 10% of body weight, plus more than 30 days of either diarrhea, or weakness and fever. Although the exact cause is not well known, several factors appear to contribute to the wasting syndrome (Roubenoff, 2000). These include poor nutrient absorption, opportunistic infections (OI) in the mouth or throat (which make eating process painful), infections in the gut, drug side effects, altered metabolism and hormone imbalance, high levels of cytokines, and finally lack of money—the latter being a critical factor in developing countries. These factors work together to accelerate disease progression and death.

Currently, there is no standard treatment for AIDS wasting, which remains poorly treatable even in countries with advanced medical care. Reducing nausea and vomiting by appetite stimulants can increase food intake. FDA-approved stimulants, megestrol acetate (megace) and d-9-tetrahydrocannabinol (dronabinol), are unfortunately associated with increase in body fat rather than lean body mass (Gorter et al, 1992; Farrar, 1999). Another frequently used approach is to provide various nutritional supplements, that is, amino acids (Shabert et al, 1999; Clark et al, 2000) and lipids or fatty acids (Singer et al, 1997; de Luis Roman et al, 2001). Some of these nutritional regimens did yield positive results albeit with variable success rate.

Hormone treatments including recombinant human growth hormone (hGH), insulin-like growth factor-I (hIGF-I), and synthetic testosterone derivatives, such as nandrolone decanoate, oxandrolone, and oxymetholone, have been examined extensively in the past (Mulligan et al, 1999). The hGH increases weight and lean body mass, while decreasing fat mass (Schambelan et al, 1996; Waters et al, 1996). However, it is expensive as it could cost at least $40 000 per year to use. Testosterone and anabolic steroids have been studied alone and in combination with exercise, and have shown promising results, especially in males (Grinspoon et al, 1998). Thalidomide was reported to reverse weight loss, but its use was limited by adverse reactions at higher doses (Kaplan et al, 2000). Thus, various therapeutic approaches for wasting are being studied and some have been quite effective. Nevertheless, many of the treatment options available in developed countries cannot be readily applied in countries with lower per capita income.

V-1 Immunitor is a low-cost, therapeutic AIDS vaccine, de-veloped and manufactured in Thailand, and has been licensed by the Thai FDA as a food supplement and investigational R&D drug. We have recently reported that orally administered V-1 Immunitor resulted in statistically significant weight gain in a small population of AIDS patients (Jirathitikal & Bourinbaiar, 2002). To expand this observation we have retrospectively evaluated body weight changes in 650 antiretroviral-drug naïve patients who have received V-1 Immunitor.

Materials and methods

Patients

Thai patients with a documented history of HIV infection were retrospectively analyzed on the basis of available baseline weight measurement and at least one post-treatment weight measurement. In majority of cases, only two weight points were available for the analysis. Not a single patient who met these criteria has been excluded and everyone who had these two data points was considered for the analysis. No other exclusion criteria have been used for the sample selection.

The patient population consisted of 319 females (51%) and 307 males (49%). The age ranged between 2.4 and 64 y with a mean age of 33 y (median 32 y). After signing standard informed consent, the patients were interviewed and examined at the Bangpakong clinic—the main site for the V-1 Immunitor study. Over 70% of the patients were symptomatic, since usually it is only at this time point of the disease that the patients realize they have been infected. After obtaining written informed consent, the subjects were given a supply of V-1 Immunitor and were instructed to come back for the next supply of vaccine. Most patients self-administered one 850 mg V-1 Immunitor tablet a day. Some took as many as four pills a day, while others took V1 breaks for 3–4 months. No stratification analysis was performed. None of the patients received any conventional antiretroviral therapy during the treatment period. Treatment duration ranged from 3 to 54 weeks with an average of 23 and a median of 25 weeks.

Vaccine

V-1 Immunitor is a polyvalent oral vaccine containing heat-inactivated, pooled HIV antigens derived from primary clinical isolates (Jirathitikal et al, 2003). The vaccine is manufactured in Thailand by Immunitor Corporation according to a proprietary process developed by Vichai Jirathitikal. V1 was licensed as a food supplement by the FDA on 13 July 2001 (License No. 152/44). Separately, in September of 2000, V1 received R&D Permit No. 1A1874/43 from the FDA for producing drug samples for R&D purposes. Thus, V1 also has a status as an experimental medicine, which will eventually lead to licensure of V1 as an immunomodulating drug or therapeutic vaccine. V-1 Immunitor is provided as an 850 mg coated pill, 10 of which are sealed in a 'blister' package. The recommended dose is one pill per day. The preparation is stable at ambient tropical temperature for 3 years.

Self-assessment of health status

A random sample of 400 letters from HIV patients who requested V1 to be sent by mail was analyzed to systematize subjective responses to the therapy. A total of 18 letters were not analyzable due to lack of information on health status. Patients' self-assessments of their own health were tabulated according to frequency and character of clinical symptoms in patients' own words.

Body weight assessment

Body weight measurements were performed with ordinary bathroom analog scales, which were synchronized on a regular basis. At least two scales were used during the study. No attempts were made to tie up particular weight measurement of a patient to a specific scale, weighing on any of the scales was random without any preference to a particular model.

Statistical analysis

Body weight data were tested with two-tailed, paired Student's t-test (StatMost version 2.5, DataMost Corp., Salk Lake City, UT, USA). The same program was used for general statistical calculations and for generation of graphs. The significance threshold was set at P0.05.

Results

Based on a random sample of patients' letters, V-1 Immunitor was extremely well tolerated by study participants; no safety concerns or serious adverse effects arose during the therapy. Among 400 letters analyzed, 18 did not contain any description of clinical symptoms and were thus excluded from analysis. The distribution of patients' own assessment of the clinical response to therapy is shown in Table 1. Subjective improvements such as patients' well-being, energy, appetite, bowel habits, regained strength, mood, and ability to resume work are shown in Table 2. A small proportion of the patients experienced minor adverse reactions, which usually did not last more than a week (Table 3). None of the patients withdrew from the study due to adverse effects. Liver and kidney function tests and other biochemical blood parameters were within normal range among treated patients. The only exception that appeared out of the ordinary is the normalization of elevated liver enzymes among hepatitis patients who had higher-than-normal transaminase and bilirubin levels at the baseline (Jirathitikal et al, 2002).

Table 1 - Distribution of subjective assessments of health status among 382 patients.

Full table

Table 2 - Distribution of beneficial effects attributed to V1 (N=323).

Full table

Table 3 - Transient adverse reactions among 35 patients.

Full table

Many of AIDS patients, especially those in advanced stages of the disease, have very limited response to standard antifungal antibiotics, for example, fluconazole. One of the most remarkable observations associated with V1 therapy is the fact that a significant proportion of the patients appear to have no evidence of exacerbated opportunistic infections. In general, patients receiving V1 are not treated with antifungal drugs, and despite the lack of treatment they were not prone to oral thrush. In patients treated with V1, the fungal infections tend to diminish or stabilize. After an average of 4 weeks on V1, about 88% of the patients seemed to have either cleared or significantly reduced oral thrush (Table 4). In approximately half of them oral thrush had cleared and in another half it has stabilized, allowing these patients to regain the ability to eat solid food. Resistant or persistent oral Candida sp was observed in only about 12% of the patients. Fungal skin infections had approximately the same rate of response.

Table 4 - Effect of V1 in 24 patients with oral thrush.

Full table

The main end point of this study is effect of V1 on body weight. A summary of the results is presented in Figure 1 and Table 5. The mean body weight of treated patients increased from baseline by 1.5 kg with an absolute range of -18 to 30 kg. The weight range at entry (baseline means.e.) was 521.9 kg and following the therapy reached 54.752.2 kg (P=6.5E-15). Among the analyzed patients, 384 (59%) patients gained an average of 4.20.2 kg; 107 (17%) had unchanged weight; and 159 (24%) had lost 3.80.3 kg. Among those who maintained unchanged weight, the average weight, was 54.6 kg. Those who lost weight tend to have higher initial weight (56.7 kg) than in the other two groups of patients.

Figure 1.

Distribution of weight loss or gain among 650 patients. Height of the bar on the vertical axis corresponds to absolute number of patients in each weight category. The highest peak corresponds to number of patients whose weight did not change.

Full figure and legend (24K)

Table 5 - Weight changes among 650 patients due to V-1 Immunitor administration.

Full table

Discussion

Wasting is a common complication of HIV infection and is recognized as a major predictive factor associated with progressive debilitation and death. The etiology of weight loss is multifactorial, ranging from lack of appetite and starvation to more complex metabolic and endocrine disturbances.

Early attempts to treat wasting were directed at stimulating appetite. Clinical studies revealed that this strategy had drawbacks and results were inconsistent. Megace had the tendency to increase fat and had undesirable side effects such as dyspnea, liver enzyme alterations, and hyperglycemia (Farrar, 1999). Patients treated with megace, which was approved by the FDA for treatment of AIDS-related cachexia, were reported to gain weight ranging from 1.8 to 10.2 kg (Batterham & Garsia, 2001). The NIH-sponsored randomized study of either megace or dronabinol, or their combination, revealed that the mean weight changes.e. over 12 weeks was as follows: dronabinol 2.5 mg twice/day (D), -2.01.3 kg; megace 750 mg/day (M750), +6.51.1 kg; M750+D, +61 kg; and M250+D, -0.31 kg (Timpone et al, 1997). Dronabinol alone, which contains the active ingredient of marijuana, was reported to cause confusion, anxiety, emotional lability, hallucinations, and had either no effect on weight or had a tendency to increase body fat (Gorter et al, 1992; Struwe et al, 1993).

The nutritional intervention is thought to be important to maximize the gain in body mass. High-energy, high-protein oral supplementation combined with nutritional counseling resulted in an overall weight change of 1.12.2 kg, with about 71% of patients gaining or maintaining the weight (Stack et al, 1996). The proportion of responding patients is similar to that in our study. However, V1 does not contain any meaningful amount of protein that could explain the weight gain. Treatment with beta-hydroxy beta-methylbutyrate, glutamine, and arginine supplements for 8 weeks resulted in 30.5 kg of weight gain, while those on placebo gained 0.370.84 kg (Clark et al, 2000). In a 3-month study, the glutamine-antioxidant supplement increased body mass by 2.2 kg, whereas the control group gained 0.3 kg (Shabert et al, 1999). An oral peptide formula with n-3 fatty acids resulted in about 3% weight gain and slightly increased CD4 counts (de Luis Roman et al, 2001). Not every nutritional regimen was found to be effective. Multivitamin and minerals supplement containing peptides and triglycerides did not increase body cell mass (Gibert et al, 1999). Similarly, immune-enhancing oral formulas consumed daily for 1 y did not appear to have any differential effect on weight or immune status (Keithley et al, 2002). Thus, various nutritional formulas for reversal of wasting have been tested but the results were unpredictable, and it is clear that additional studies are needed to identify the most effective regimens. The most promising supplement to date is a humanized native milk serum protein isolate named Immunocal™ (Immunotec Research Corporation, Canada), which increases the production of glutathione. It has shown anti-HIV, anticancer, and antiapoptotic activity in vitro and in vivo, and resulted in a weight gain in the range of 3.2–22% (mean 8.4%) in wasted children with AIDS (Baruchel et al, 1996).

Trials with human growth hormone to control wasting in patients with AIDS have been encouraging, but with limited evidence of sustainable benefit (Schambelan et al, 1996). Waters et al (1996) reported use of hGH, hIGF-I, or both. The group that has been treated with both hormones had the greatest changes in lean body mass, 3.20.6 kg. However, the authors cautioned that if hGH or hIGF-I were used alone, weight gains were transient and did not persist beyond 12 weeks (Waters et al, 1996). The doses of hGH administered for AIDS wasting (about 0.1 mg/kg) are higher compared with other clinical indications. While there is a consensus that hGH is useful for the treatment of wasting, concerns have been raised recently that in patients with prolonged critical illness, high doses of growth hormone were associated with increased morbidity and mortality (Takala et al, 1999). While this observation may not necessarily apply to AIDS, this treatment option is not realistic in developing countries. The $7000 per month price tag is not the only reason to use hGH judiciously, since in AIDS wasting trials, the incidence of muscle pain (54%), tissue swelling and stiffness (27%), and carpal tunnel syndrome was markedly elevated.

Wasting in men has been frequently associated with hypogonadism, particularly low testosterone, and replacing lost testosterone reverses the attrition of lean body mass (Rabkin et al, 1999). When used in women, anabolic steroids also produce weight gain but primarily in the form of fat. In contrast, V1 does not appear to promote fat gain; however, this needs to be further tested by more objective tests like bioimpedance test. In a randomized study, testosterone-treated patients gained 2 kg of fat-free mass as opposed to loss of 0.6 kg in patients on placebo (Grinspoon et al, 1998). Similar to V1 experience, patients who received testosterone reported that they felt better, had improved quality of life, and improved appearance. When testosterone was combined with exercise, the body weight increased by 2.6 kg in men on testosterone alone and by 2.2 kg in men who exercised; but weight was reduced by 0.5 kg in men receiving placebo (Bhasin et al, 2000). Synthetic anabolic steroids mimicking testosterone, for example, oxandrolone, oxymetholone, and nandrolone, have also been tested in AIDS patients with variable success (Hengge et al, 1996; Strawford et al, 1999; Taiwo, 2000). Testosterone replacement therapy is generally considered safe, the main adverse effect being the reduction of HDL cholesterol with additional side effects like acne, hair loss, dyslipidemia, sleep apnea, prostate changes with neoplastic growth potential, and prospect of hepatic failure in patients with liver disease. However, even though the total yearly cost for the cheapest anabolic is about $600, it is still beyond the reach of most patients in developing countries.

It has been hypothesized that a higher level of cytokines, such as tumor necrosis factor (TNF), may result in increased energy expenditure and wasting, and thus treating AIDS patients with alleged TNF antagonist thalidomide might reverse the weight loss. Three studies of thalidomide have been conducted showing an increase in body cell mass and a decrease in urinary nitrogen excretion. A Mexican 12-week study reported that weight gain occurred in eight patients (57%) on thalidomide — a rate of response similar to V1 (Reyes-Teran et al, 1996). A more recent study demonstrated a significant weight gain with 100 or 200 mg/day doses, although the higher dose was poorly tolerated (Kaplan et al, 2000). The mean change in body weight of the placebo, 100 mg, and 200 mg treatment groups was 0.3, 2.0, and 0.9 kg, respectively, and half of the weight gain was fat-free mass. As in our earlier V1 study, total lymphocyte counts and CD8 T-cell counts increased due to thalidomide intake. A modest gain in CD4 T-cell counts was also observed, but unlike the V1 study the viral load increased two-fold in the course of the trial.

Not long ago the inclusion of protease inhibitors in highly aggressive antiviral therapy (HAART) was believed to increase the body weight of treated patients (Scevola et al, 2000). In a study involving 214 HIV-positive individuals, in 74.4% of the patients the mean weight gain was 6.33.8 kg (range 1–18 kg), in 13 (8.1%) weight has not changed, and in 28 (17.5%) weight had fallen (4.23.0 kg; range 1–12 kg). However, these figures are misleading since they are not based on the total population but on a subpopulation of 160 patients who were followed for a median of 176 days. In reality, only 119 out of 214 (55.6%) patients had gained weight, a proportion comparable to 59% in our study (Carbonnel et al, 1998). More recent studies indicated that HAART is associated with redistribution of fat mass from the legs to the trunk with no significant alteration in total body mass (McDermott et al, 2001). Longitudinal data analysis of 38 patients had shown that although weight increased by 1.54 kg, the gain was mainly in the form of fat (Silva et al, 1998). Thus, contrary to the original belief that HAART reverses weight loss, the current consensus is that wasting is not corrected by antiviral drugs (Wanke et al, 2000). Furthermore, the proportion of patients who lose weight while on aggressive antiviral therapies is about a fifth to a quarter—a proportion comparable to our patient sample.

Therapies are still being sought for treating weight loss attributable to HIV infection. Available treatment options are prohibitively expensive for developing countries where many people often cannot buy even food. Furthermore, patients with documented weight loss seldom recover even when given antiviral drugs or simple OI prophylaxis. Our recent study demonstrated that emaciated, terminal-stage AIDS patients treated with V1 had significantly higher chances of long-term survival than nontreated patients with access to OI antibiotics (Metadilogkul et al, 2002). In the present study, patients treated with V1 have reduced rate of opportunistic infections, that is, oral thrush. V1-treated patients were able to regain the appetite, sense of taste, and ability to eat solid food, which we believe are relevant to the reversal of wasting. However, the observed weight gain cannot be attributed solely to increase in food intake since it is known that this factor alone does not improve the condition of the patients (Izquierdo et al, 2000).

Finally, the extent of clinical response to V1 does not seem to be worse if not superior than current therapies for weight loss. V1, however, is safer and significantly cheaper than available weight management therapies. Our findings suggest that V1 can play an important role in the management of malnourished HIV-infected patients.

References

1. Baruchel S, Viau G, Olivier G, Bounous G & Wainberg MA (1996): Nutraceutical modulation of glutathione with a humanized native milk serum protein isolate Immunocal: application in AIDS and cancer. In: Oxidative Stress in Cancer AIDS and Neurodegenerative Diseases, eds L Montagnier, R Olivier & C Pasquier, pp 447–461. New York: Marcel Dekker.
2. Batterham MJ & Garsia R (2001): A comparison of megestrol acetate, nandrolone decanoate and dietary counselling for HIV associated weight loss. Int. J. Androl. 24, 232–240. | PubMed |
3. Bhasin S, Storer TW, Javanbakht M, Berman N, Yarasheski KE, Phillips J, Dike M, Sinha-Hikim I, Shen R, Hays RD & Beall G (2000): Testosterone replacement and resistance exercise in HIV-infected men with weight loss and low testosterone levels. JAMA 283, 763–770. | Article | PubMed | ISI | ChemPort |
4. Carbonnel F, Maslo C, Beaugerie L, Carrat F, Wirbel E, Aussel C, Gobert JG, Girard PM, Gendre JP, Cosnes J & Rozenbaum W (1998): Effect of indinavir on HIV-related wasting. AIDS 12, 1777–1784. | PubMed |
5. Clark RH, Feleke G, Din M, Yasmin T, Singh G, Khan FA & Rathmacher JA (2000): Nutritional treatment for acquired immunodeficiency virus-associated wasting using beta-hydroxy beta-methylbutyrate, glutamine, and arginine: a randomized, double-blind, placebo-controlled study. J. Parenter. Enter. Nutr. 24, 133–139.
6. de Luis Roman DA, Bachiller P, Izaola O, Romero E, Martin J, Arranz M, Eiros Bouza JM & Aller R (2001): Nutritional treatment for acquired immunodeficiency virus infection using an enterotropic peptide-based formula enriched with n-3 fatty acids: a randomized prospective trial. Eur. J. Clin. Nutr. 55, 1048–1052. | Article |
7. Farrar DJ (1999): Megestrol acetate: promises and pitfalls. AIDS Patient Care STDS 13, 149–152. | PubMed |
8. Gibert CL, Wheeler DA, Collins G, Madans M, Muurahainen N, Raghavan SS & Bartsch G (1999): Randomized, controlled trial of caloric supplements in HIV infection. Terry Beirn Community Programs for Clinical Research on AIDS. J. Acquir. Immune Defic. Syndr. 22, 253–259. | PubMed |
9. Gorter R, Seefried M & Volberding P (1992): Dronabinol effects on weight in patients with HIV infection. AIDS 6, 127–128. | PubMed |
10. Grinspoon S, Corcoran C, Askari H, Schoenfeld D, Wolf L, Burrows B, Walsh M, Hayden D, Parlman K, Anderson E, Basgoz N & Klibanski A (1998): Effects of androgen administration in men with the AIDS wasting syndrome. A randomized, double-blind, placebo-controlled trial. Ann. Intern. Med. 129, 18–26.  | PubMed | ISI | ChemPort |
11. Hengge UR, Baumann M, Maleba R, Brockmeyer NH & Goos M (1996): Oxymetholone promotes weight gain in patients with advanced human immunodeficiency virus (HIV-1) infection. Br. J. Nutr. 75, 129–138. | PubMed |
12. Izquierdo Villarroya B, Celaya Perez S & Amiguet Garcia JA (2000): Nutritional status of the HIV patient. Description and clinical course of a group of patients over a year. Nutr. Hosp. 15, 302–311. | PubMed |
13. Jirathitikal V & Bourinbaiar AS (2002): Safety and efficacy of an oral HIV vaccine (V-1 Immunitor) in AIDS patients at various stages of the disease. HIV Clin. Trials 3, 21–26. | PubMed |
14. Jirathitikal V, Metadilogkul O & Bourinbaiar AS (2002): Normalization of elevated liver enzymes due to V-1 Immunitor therapy. Antiviral Ther. 7(Suppl), L115–L116 (abstract).
15. Jirathitikal V, Sooksathan P, Metadilogkul O & Bourinbaiar AS (2003): V-1 Immunitor: oral AIDS vaccine with therapeutic and prophylactic potential. Vaccine 21, 624–628. | PubMed |
16. Kaplan G, Thomas S, Fierer DS, Mulligan K, Haslett PA, Fessel WJ, Smith LG, Kook KA, Stirling D & Schambelan M (2000): Thalidomide for the treatment of AIDS-associated wasting. AIDS Res. Hum. Retrovirus 16, 1345–1355.
17. Keithley JK, Swanson B, Zeller JM, Sha BE, Cohen M, Hershow R & Novak R (2002): Comparison of standard and immune-enhancing oral formulas in asymptomatic HIV-infected persons: a multicenter randomized controlled clinical trial. J. Parenter. Enteral Nutr. 26, 6–14.
18. Metadilogkul O, Jirathitikal V & Bourinbaiar AS (2002): Survival of end-stage AIDS patients receiving V-1 Immunitor. HIV Clin. Trials 3, 258–259. | PubMed |
19. McDermott AY, Shevitz A, Knox T, Roubenoff R, Kehayias J & Gorbach S (2001): Effect of highly active antiretroviral therapy on fat, lean, and bone mass in HIV-seropositive men and women. Am. J. Clin. Nutr. 74, 679–686. | PubMed |
20. Mulligan K, Tai VW & Schambelan M (1999): Use of growth hormone and other anabolic agents in AIDS wasting. J. Parenter. Enteral Nutr. 23, S202–S209.
21. Rabkin JG, Wagner GJ & Rabkin R (1999): Testosterone therapy for human immunodeficiency virus-positive men with and without hypogonadism. J. Clin. Psychopharmacol. 19, 19–27. | Article | PubMed | ISI | ChemPort |
22. Reyes-Teran G, Sierra-Madero JG, Martinez del Cerro V, Arroyo-Figueroa H, Pasquetti A, Calva JJ & Ruiz-Palacios GM (1996): Effects of thalidomide on HIV-associated wasting syndrome: a randomized, double-blind, placebo-controlled clinical trial. AIDS 10, 1501–1507. | PubMed | ChemPort |
23. Roubenoff R (2000): Acquired immunodeficiency syndrome wasting, functional performance, and quality of life. Am. J. Manag. Care 6, 1003–1016. | PubMed | ISI |
24. Scevola D, Di Matteo A, Uberti F, Minoia G, Poletti F & Faga A (2000): Reversal of cachexia in patients treated with potent antiretroviral therapy. AIDS Read. 10, 365–375. | PubMed |
25. Schambelan M, Mulligan K, Grunfeld C, Daar ES, LaMarca A, Kotler DP, Wang J, Bozzette SA & Breitmeyer JB (1996): Recombinant human growth hormone in patients with HIV-associated wasting. A randomized, placebo-controlled trial. Serostim Study Group. Ann. Intern. Med. 125, 873–882. | PubMed | ISI | ChemPort |
26. Shabert JK, Winslow C, Lacey JM & Wilmore DW (1999): Glutamine-antioxidant supplementation increases body cell mass in AIDS patients with weight loss: a randomized, double-blind controlled trial. Nutrition 15, 860–864. | Article | PubMed | ChemPort |
27. Silva M, Skolnik PR, Gorbach SL, Spiegelman D, Wilson IB, Fernandez-DiFranco MG & Knox TA (1998): The effect of protease inhibitors on weight and body composition in HIV-infected patients. AIDS 12, 1645–1651. | Article | PubMed | ChemPort |
28. Singer P, Levine R, Rothkopf M & Askanazi J (1997): Home parenteral lipids in AIDS: a three-month study. Nutrition 13, 104–109. | PubMed |
29. Stack JA, Bell SJ, Burke PA & Forse RA (1996): High-energy, high-protein, oral, liquid, nutrition supplementation in patients with HIV infection: effect on weight status in relation to incidence of secondary infection. J. Am. Diet. Assoc. 96, 337–341. | PubMed |
30. Strawford A, Barbieri T, Neese R, Van Loan M, Christiansen M, Hoh R, Sathyan G, Skowronski R, King J & Hellerstein M (1999): Effects of nandrolone decanoate therapy in borderline hypogonadal men with HIV-associated weight loss. J. Acquir. Immune Defic. Syndr. Hum. Retrovirol. 20, 137–146. | PubMed |
31. Struwe M, Kaempfer SH, Geiger CJ, Pavia AT, Plasse TF, Shepard KV, Ries K & Evans TG (1993): Effect of dronabinol on nutritional status in HIV infection. Ann. Pharmacother. 27, 827–831.  | PubMed | ISI | ChemPort |
32. Taiwo BO (2000): HIV-associated wasting: brief review and discussion of the impact of oxandrolone. AIDS Patient Care STDS 14, 421–425. | PubMed |
33. Takala J, Ruokonen E, Webster NR, Nielsen MS, Zandstra DF, Vundelinckx G & Hinds CJ (1999): Increased mortality associated with growth hormone treatment in critically ill adults. N. Engl. J. Med. 341, 785–792. | Article | PubMed | ISI | ChemPort |
34. Timpone JG, Wright DJ, Li N, Egorin MJ, Enama ME, Mayers J & Galetto G (1997): The safety and pharmacokinetics of single-agent and combination therapy with megestrol acetate and dronabinol for the treatment of HIV wasting syndrome. The DATRI 004 Study Group. Division of AIDS Treatment Research Initiative. AIDS Res. Hum. Retrovir. 13, 305–315.
35. Wanke CA, Silva M, Knox TA, Forrester J, Speigelman D & Gorbach SL (2000): Weight loss and wasting remain common complications in individuals infected with human immunodeficiency virus in the era of highly active antiretroviral therapy. Clin. Infect. Dis. 31, 803–805. | PubMed |
36. Waters D, Danska J, Hardy K, Koster F, Qualls C, Nickell D, Nightingale S, Gesundheit N, Watson D & Schade D (1996): Recombinant human growth hormone, insulin-like growth factor 1, and combination therapy in AIDS-associated wasting. A randomized, double-blind, placebo-controlled trial. Ann. Intern. Med. 125, 865–872. | PubMed | ChemPort |

Acknowledgements

We thank all individuals who participated in this study. We had warm support and encouragement from many patients and clinicians around the world and are thankful to all of them. All costs in developing V-1 Immunitor were borne by our families and friends.