Body composition can provide valuable information in the management of women with HIV.

Untreated infection with the human immunodeficiency virus (HIV) leads to severe physical debilitation, culminating in the acquired immune deficiency syndrome (AIDS). Multiple infections, body mass loss, physical weakness and wasting are characteristic manifestations of each of the four stages of HIV/AIDS, respectively (Table I). The latter two impact especially on the affected person's ability to function, as well as on social and economic levels. However, even though antiretroviral treatment (ART) is now available at many selected public clinics in South Africa, it only complicates the issues surrounding body composition and physical function.

AIDS-related wasting and ART-related lipodystrophy are physical conditions affecting the patient and can be monitored on a regular basis. The physical assessments should be practical, i.e. cost and time efficient, objective, accurate and relevant. With proper training, determination of body composition using anthropometry (measurement of skinfold thickness and various circumference measurements) fulfils these criteria. The information gained could lead the medical practitioner to recommend lifestyle changes, including exercise, which will further benefit the patient over and above the use of ART.

Finally, according to UNAIDS and the WHO, 57% of people living with HIV in sub-Saharan Africa are women. Therefore, this review focuses (where possible) on the physical effects of HIV on infected women and the impact of ART on this population.

The AIDS wasting syndrome (AWS)

Wasting is directly associated with HIV/ AIDS disease progression. A body mass loss greater than 10% before AIDS is associated with an increased risk of death. (1) Even a body mass loss of between 5% and 10% has been associated with an increased risk of opportunistic complications. However, although measurement of body mass is practical, it may be too insensitive, as patients with a small body mass loss may actually be losing a greater amount of essential lean body mass (LBM).

* Melchior et al. (2) found that LBM index (LBM (kg)/height (2) ([m.sup.2])) was an independent predictor of survival in patients with HIV/AIDS, irrespective of body mass.

* Interventions that restore muscle mass are therefore critical for patients suffering from the wasting syndrome, or for those who suffered from it before being on ART.

A drawback of many published studies on HIV/AIDS is that most of the study participants were men. In contrast to men, women lose proportionately more fat during HIV infection; (3,4) therefore, in comparison, they preserve more lean tissue. A higher initial body fat content may predispose women to lose relatively more fat than LBM during wasting. However, conclusions drawn from women living in a Western society will not necessarily reflect those found in sub-Saharan Africa where socio-economic factors and ethnicity could influence body composition changes.

Mechanisms of wasting in patients with HIV/AIDS

There are often multiple underlying causes of the wasting process. Opportunistic infections, chronic diarrhoea, decreased dietary energy intake and increased resting energy expenditure (hypermetabolism) are correlated with body mass loss. (2) Primary muscle disease has been implicated as another possible underlying mechanism of the wasting syndrome. (5,6)

* Hypermetabolism is related to endocrine abnormalities or elevated cytokines, or both:

* HIV-positive patients may have elevated resting cortisol concentrations (which can lead to increased tissue catabolism) and decreased dihydro-epiandrosterone sulphate (DHEAS)(which is anticatabolic). (7)

* Cytokines cause anorexia (cachexia in extreme cases), but also stimulate muscle proteolysis by activating the ubiquitin-proteosome pathway. (5)

* Deltoid muscle biopsy samples of 30 patients (of whom 26 were male) with the wasting syndrome, revealed that 11 patients had HIV-related myopathy. (6)

The lipodystrophy syndrome

Currently, there are three classes of ART medications: nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs). Many of the typical side-effects can affect functional capacity (Table II). In general, in South Africa, stavudine, lamivudine and efavirenz (Stocrin) are used as the first line of treatment, whereas didanosine, zidovudine and lamivudine/zidovudine (Combivir) are used in cases of treatment failure (insufficient viral suppression despite compliance) or if there are other reasons to alter treatment (e.g. lactic acidosis).

Disturbances in lipid metabolism leading to lipodystrophy, hyperlipidaemia, insulin resistance and hyperglycaemia are strongly associated with PI-based ART. (8,9) However, PI-naive patients treated with two NRTIs have also been shown to exhibit the same manifestations. (10) Even though ART can reduce generalised body mass loss and improve longevity, the impact on body composition may be negative, (8,9) e.g.:

* fat loss in the face, arms and legs

* increased waist circumference due to deposition of intra-abdominal visceral fat

* accumulation of adipose tissue in areas such as the dorso-cervical region of the neck and breasts, sometimes in the form of unencapsulated lipomas.

Lipodystrophy is an adverse effect of ART, and not limited to a specific drug or class of drugs.

These ART-associated features (Table III) resemble some characteristics of the metabolic syndrome, and therefore can be aggravated by high fat intake, chronic psychological stressors and low physical activity, leading to further complications such as fatty liver, hypertension, endothelial dysfunction, renal dysfunction, inflammation, hyper-coagulability and atherosclerosis. (11)

* The defining physical features of the metabolic syndrome are: body mass index (BMI) >30 kg/[m.sup.2], waist circumference >102 cm (men) or >89 cm (women), or a waist-to-hip ratio >0.90 (men) and >0.85 (women).

* Endurance exercise is frequently promoted as a lifestyle intervention for the metabolic syndrome and should also be implemented in HIV-positive persons on ART.

As fat deposited in the intra-abdominal area could be a result of redistribution of existing fat (12,13) or the preferential deposition of 'new' fat, it is important to monitor not only a global percentage of body fat but also regional distribution.

Monitoring body composition changes

Portable methods for assessing body composition include bio-electrical impedance analysis (BIA) and skinfold measurements. Different equations used with BIA resulted in highly variable estimations of fat-free mass (FFM) and fat mass (FM) in HIV-infected individuals showing signs of AIDS wasting, (14) and may not be the method of choice for this population. To improve the reliability of skinfold measurements, the same technician should perform measurements repeated on the same patients. Measurement of circumferences at specific sites is also simple to perform and is reliable, provided the specific landmarks are understood. Table IV summarises anthropometric variables related to wasting or lipodystrophy.

The only variable in traditional anthropometry related to lipodystrophy is the waist-to-hip ratio, but it does not distinguish between subcutaneous and intra-abdominal fat. It is also affected by gluteal wasting (12) that would exacerbate an already abnormal waist-to-hip ratio. However, the female body tends to store fat more easily in the gluteal area, which could mask gluteal wasting in women.

A longitudinal study conducted by Galli et al. (15) found simultaneous fat loss and fat accumulation in HIV-positive women on ART followed up for 12 months, with further progression (especially peripheral lipoatrophy) after 24 months. It is also possible for lipoatrophy to occur without the concomitant increase in waist circumference. (16) Of 14 patients with a clinically abnormal reduction or an absence of subcutaneous fat in the cheeks, 6 did not have an enlarged abdomen, while 5 had abnormally reduced fat in the legs and arms without an enlarged abdomen.

Exercise--effective intervention to reduce wasting and lipodystrophy

Oral nutritional supplementation combined with dietary counselling can diminish whole-body protein catabolism and increase LBM in HIV-positive patients with modest-to-moderate malnutrition. Although positive effects of whey protein supplementation on body mass were found, Agin et al. (17) also showed that the combination of supplementation and resistance exercise led to gains in LBM, whereas supplementation alone increased fat mass.

* Resistance training is an effective treatment to increase LBM, strength and functional status in patients with HIV/ AIDS. (18)

* Progressive resistance training with an aerobic component, undertaken for 16 weeks, reduced trunk fat mass in patients on ART. (19)

* Increased LBM lasted up to 8 weeks after a resistance training programme was discontinued. (20)

Grinspoon et al. (21) showed that androgen administration increases LBM and quality of life (QoL), but testosterone administration in combination with resistance exercise resulted in similar increases in skeletal muscle fibre size compared with testosterone alone, suggesting exercise was not essential. However, Bhasin et al., (22) who also found that testosterone and exercise together did not produce greater gains than testosterone alone, showed that exercise alone was sufficient.

* Considering longer-term side-effects of androgen treatment, exercise alone may be a better long-term strategy to prevent or reverse muscle loss in HIV-infected persons.

Shevitz et al. (23) compared the effectiveness of nutritional intervention alone, nutrition with oral androgen (oxandrolone), and nutrition with progressive resistance training. The mid-thigh muscle cross-sectional area increased significantly only when nutrition was administered with oxandrolone or with resistance training, indicating that nutrition alone is not sufficient.

* Self-reported physical functioning improved significantly with resistance training.

* QoL improved more with exercise than with nutrition or nutrition plus androgen interventions.

* Exercise is more cost effective.

Although strength training and cardiovascular exercise have been suggested as treatment interventions for the AWS, and more recently to address the metabolic abnormalities associated with ART, (19,24) there is a distinct lack of data on the longitudinal effects of cardiovascular exercise although it has been shown to be safe. (25,26)

[FIGURE 1 OMITTED]

Quality of life

The number and severity of HIV-related symptoms are associated with a patient's perceived QoL. (27) QoL includes multiple aspects of life satisfaction related to physical functioning, mental health status and functioning within social roles. (28) Physical functioning includes variables such as self-care, mobility and fatigue.

The MOS-HIV questionnaire (HIV-specific scales adapted from the Medical Outcomes Survey) is a widely used instrument to assess QoL. An European questionnaire (EQ-5D) has been used extensively in various countries (including Japan, Canada and Zimbabwe), and has been translated into Xhosa and validated in a South African population.

Health-promoting behaviours, including exercise, improved mental health, physical functioning and overall QoL in women with HIV who had various socioeconomic and educational stratifications. (28) The researchers concluded that relatively straightforward lifestyle changes (such as eating well, exercising and adequate sleep) can make a difference, even in a complicated context involving HIV, poverty and oppression. Resistance training and cycling have also been shown to increase QoL and physical functioning in HIV-infected men and women. (19,26,29)

Muscle wasting and impaired QoL in a pilot study of 8 women with HIV in a South African semi-rural clinic

Just before initiating ART, the percentage of ideal body mass (%IBW) of the patients ranged from 67 to 153. Therefore, it should be noted that many infected individuals have an initial body mass much greater than 100%. Nonetheless, the upper arm showed signs of wasting of both muscle and fat (low percentage ideal arm circumference (%IAC)) despite the fact that mean %IBW was normal (Table V). Such individuals could be experiencing the wasting syndrome (loss of LBM and regional loss of fat mass) without having a body mass less than 10% of the ideal. For example, one participant was classified with late-stage (WHO stage 4) disease and her calculated upper arm muscle area (UAMA) was below the 5th percentile threshold, but her body mass was only 1% below the ideal prescribed for a female of her height, suggesting muscle wasting but not fat wasting.

Fig. 1 shows the proportion of these women who reported no problems, some problems or severe problems for each of the five QoL dimensions (before ART). Patients had difficulties with mobility and usual activities.

Conclusions

There is a complex interaction between disease and treatment, and body composition, physical activity and QoL in patients with HIV/AIDS. Monitoring of body mass alone is insufficient to understand the dynamic of the patient. Insufficient data are available, particularly in women, but normal body mass and fat deposition in the hip area may mask muscle and fat atrophy in other peripheral sites. The role of exercise in the long-term management strategy is essential for the health and QoL of patients before ART and for those on ART in order to reverse wasting and ameliorate lipodystrophy and the accompanying metabolic abnormalities.

In a nutshell

* AIDS-related wasting and ART-related lipodystrophy are physical conditions that should be monitored on a regular basis.

* Body mass loss between 5% and 10% has been associated with an increased risk of opportunistic complications.

* Patients with only a small body mass loss may actually be losing a greater amount of essential lean body mass (LBM).

* Cytokines play a role by causing anorexia (cachexia in extreme cases), but also stimulate muscle proteolysis by activating the ubiquitin-proteosome pathway.

* One-third of patients may have HIV-related myopathy.

* Currently lipodystrophy is an adverse effect of ART, not limited to a specific drug or class of drugs, but more commonly associated with protease inhibitors.

* Intra-abdominal fat deposition and loss of facial and peripheral fat are features of lipodystrophy.

* Assessment of skinfold thickness and circumferences is cost effective, but requires proper training for reliable measurements.

* Lipodystrophy shares many features with the metabolic syndrome, for which endurance exercise is known to be beneficial.

* Interventions that restore muscle mass are critical for patients suffering from the wasting syndrome, or for those who suffered from it before being on ART. Endurance exercise is important for patients on ART.

Acknowledgements

We wish to thank everyone at the T C Newman Day Hospital HIV Clinic, Paarl, and the Idas Valley Clinic, Stellenbosch, especially Drs Nelis Grobbelaar and Joyce Malaka for seeing opportunities where others see problems. I am grateful for discussions with Drs Carine Smith, Theo Nell and Myriam Moyen, Department of Physiological Sciences, Stellenbosch University.

References

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(2.) Melchior J-C, Niyongabo T, Henzel D, et al. Malnutrition and wasting, immunodepression, and chronic inflammation as independent predictors of survival in HIV-infected patients. Nutrition 1999; 15: 865-869.

(3.) Kotler DP, Thea DM, Heo M, et al. Relative influences of sex, race, environment, and HIV infection on body composition in adults. Am J Clin Nutr 1999; 69: 432-439.

(4.) Swanson B, Hershow RC, Sha BE, et al. Body composition in HIV-infected women. Nutrition 2000; 16: 1064-1068.

(5.) Chang HR, Dulloo AG, Bistrian BR. Role of cytokines in AIDS wasting. Nutrition 1998; 14: 853-863.

(6.) Miro O, Pedrol E, Cebrian M, et al. Skeletal muscle studies in patients with HIV-related wasting syndrome. J Neurol Sci 1997; 150: 153-159.

(7.) Christeff N, Nunez EA, Gougeon M-L. Changes in cortisol/DHEA ratio in HIV-infected men are related to immunological and metabolic perturbations leading to malnutrition and lipodystrophy. Ann N Y Acad Sci 2000; 917: 962-970.

(8.) Brinkman K, Smeitink JA, Romijn JA, et al. Mitochondrial toxicity induced by nucleoside-analogue reverse-transcriptase inhibitors is a key factor in the pathogenesis of antiretroviral-therapy-related lipodystrophy. Lancet 1999; 354: 1112-1115.

(9.) Carr A, Samaras K, Thorisdottir A, et al. Diagnosis, prediction, and natural course of HIV1-protease-inhibitor-related lipodystrophy, hyperlipidaemia, and diabetes mellitus: a cohort study. Lancet 1999; 353: 2093-2099.

(10.) Galli M, Ridolfo AL, Adorni F, et al. Body habitus changes and metabolic alterations in protease inhibitor-naive HIV-1 infected patients treated with two nucleoside reverse transcriptase inhibitors. J Acquir Immune Defic Syndr 2002; 29(1): 21-31.

(11.) Miranda PJ, DeFronzo RA, Califf RM, et al. Metabolic syndrome: Definition, pathophysiology, and mechanisms. Am Heart J 2005; 149: 33-45.

(12.) Gervasoni C, Ridolfo AL, Trifiro G, et al. Redistribution of body fat in HIV-infected women undergoing combined antiretroviral therapy. AIDS 1999; 13: 465-471.

(13.) McDermott AY, Shevitz A, Knox T, et al. Effect of highly active antiretroviral therapy on fat, lean, and bone mass in HIV-seropositive men and women. Am J Clin Nutr 2001; 74: 679-686.

(14.) Corcoran C, Anderson EJ, Burrows B, et al. Comparison of total body potassium with other techniques for measuring lean body mass in men and women with AIDS wasting. Am J Clin Nutr 2000; 72: 1053-1058.

(15.) Galli M, Ridolfo AL, Adorni F, et al. Correlates of risk of adipose tissue alterations and their modifications over time in HIV-1-infected women treated with antiretroviral therapy. Antivir Ther 2003; 8: 347-354.

(16.) Rodwell GE, Maurer TA, Berger TG. Fat redistribution in HIV disease. J Am Acad Dermatol 2000; 42: 727-730.

(17.) Agin D, Kotler DP, Papandreou D, et al. Effects of whey protein and resistance exercise on body composition and muscle strength in women with HIV infection. Ann N Y Acad Sci 1999; 904: 607-609.

(18.) Roubenoff R, Wilson IB. Effect of resistance training on self-reported physical functioning in HIV infection. Med Sci Sports Exerc 2001; 33(11): 1811-1817.

(19.) Roubenoff R, Weiss L, McDermott A, et al. A pilot study of exercise training to reduce trunk fat in adults with HIV-associated fat redistribution. AIDS 1999; 13: 1373-1375.

(20.) Roubenoff R, McDermott A, Weiss L, et al. Short-term progressive resistance training increases strength and lean body mass in adults infected with human immunodeficiency virus. AIDS 1999; 13: 231-239.

(21.) Grinspoon S, Corcoran C, Parlman K, et al. Effects of testosterone and progressive resistance training in eugonadal men with AIDS wasting. A randomized, controlled trial. Ann Intern Med 2000; 133: 348-355.

(22.) Bhasin S, Storer TW, Javanbakht M, et al. Testosterone replacement and resistance exercise in HIV-infected men with weight loss and low testosterone levels. JAMA 2000; 283(6): 763-770.

(23.) Shevitz AH, Wilson IB, McDermott AY, et al. A comparison of the clinical and cost-effectiveness of 3 intervention strategies for AIDS wasting. J Acquir Immune Defic Syndr 2005; 38(4): 399-406.

(24.) Mars M. HIV infection and exercise. South African Journal of Sports Medicine 2000; 7: 3-10.

(25.) Scevola D, Matteo AD, Lanzarini P, et al. Effect of exercise and strength training on cardiovascular status in HIV-infected patients receiving highly active antiretroviral therapy. AIDS 2003; 17(Suppl 1): S123-S129.

(26.) Stringer WW, Berezovskaya M, O'Brien WA, et al. The effect of exercise training on aerobic fitness, immune indices, and quality of life in HIV+ patients. Med Sci Sports Exerc 1998; 30(1): 11-16.

(27.) Cleary PD, Fowler FJ, Weissman J, et al. Health related quality of life among persons with AIDS. Med Care 1993; 31: 569-580.

(28.) Gielen AC, McDonnell KA, Wu AW, et al. Quality of life among women living with HIV: the importance, violence, social support, and self care behaviours. Soc Sci Med 2001; 52: 315-322.

(29.) Agin D, Gallagher D, Wang J, et al. Effects of whey protein and resistance exercise on body cell mass, muscle strength, and quality of life in women with HIV. AIDS 2001; 15: 2431-2440.

KATHRYN H MYBURGH, PhD (Physiology)

Head, Department of Physiological Sciences, Science Faculty, Main Campus, Stellenbosch University

Kathryn Myburgh is chairperson of the Board, Stellenbosch University Centre for Human Performance Sciences--a trans- faculty initiative to promote interdisciplinary research. She heads the National Research Foundation Research Niche Area for Integrative Skeletal Muscle Biology, is president of the Physiology Society of Southern Africa (PSSA), and is a member of the editorial boards of Medicine and Science in Sports and Exercise and Biomed Central Physiology. Her current interests are muscle adaptation, atrophy, and inflammation; muscle stem cell-like satellite cells; promoting wellness in patients with HIV/AIDS; and the metabolic syndrome.

PETRO C DE BRUTO, MPhil (Exercise Science)

Department Physiological Sciences, Stellenbosch University

Petro de Bruto is a former postgraduate student in exercise science at Stellenbosch University.

Table I. The WHO classification system for HIV infection
(rewritten from Weatherall DJ, Ledingham JGG, Warrell DA. Oxford
Textbook of Medicine. 3rd ed. Oxford, UK: Oxford University Press,
1996)

           Group A-C based on laboratory variables

           Lymphocyte count   [CD4.sup.+] count
           (x [10.sup.6]/l)   (x [10.sup.6]/l)

A          >2 000             >500
B          1 000-2 000        200-500
C          <1 000             <200

           Group 1-4 based on clinical variables

Clinical   HIV infected: Asymptomatic or with only persistent
group 1    generalised lymphadenopathy

           Exercise: Can participate in normal physical activities

Clinical   Early-stage disease: Symptomatic with body mass loss of
group 2    <10%

           Symptoms: recurrent upper respiratory tract infections and
           herpes zoster (shingles) infection occurring within 5 years

           Exercise: Can still maintain normal physical activity

Clinical   Intermediate-stage disease: Body mass loss >10%,
group 3    unexplained chronic diarrhoea for >1 month, unexplained
           prolonged fever for >1 month, oral candidiasis, oral hairy
           leukoplakia, pulmonary tuberculosis within previous 12
           months, severe bacterial infections

           Physical ability: Frequently bedridden, but <50% of the
           day/s during the previous month

Clinical   Late stage disease: Diagnosed with any of the
group 4    AIDS-defining illnesses

           Physical ability: Bedridden >50% of the day/s during the
           previous month

Table II. Antiretroviral medications and side-effects that could impact
on body composition and willingness or ability to exercise (adapted from
Baylor College of Medicine, 2003. HIV curriculum for the health
professional (www.bcm.edu)) *

Class   Antiretroviral drug         Possible side-effects

NRTI    Didanosine (ddI) (Videx)    Common: nausea, vomiting, diarrhoea

                                    Severe: peripheral neuropathy,
                                    electrolyte abnormalities, lactic
                                    acidosis

        Lamivudine (3TC)(Epivir)    Common: nausea, diarrhoea,
                                    headache, fatigue

                                    Severe: lactic acidosis

        Zalcitabine (ddC) (Hivid)   Common: headache, malaise

                                    Severe: peripheral neuropathy,
                                    haematological toxicity

        Zidovudine (AZT)            Common: haematological toxicity,
        (Retrovir; Zidovir)         headache

                                    Less common: myopathy, myositis

        Stavudine (d4T) (Stavir;    Common: headache, nausea, vomiting,
        Zerit)                      diarrhoea

                                    Severe: peripheral neuropathy,
                                    lactic acidosis

        Abacavir (in Trizivar;      Common: nausea, vomiting,
        Ziagen)                     diarrhoea, loss of appetite,
                                    malaise, headache

        Tenofovir (Disoproxil,      Common: headache, nausea, lactic
        Fumarate, Viread)           acidosis

        Zidovudine/lamivudine       Common: lactic acidosis
        (Combivir or Duovir; in
        Trizivar)

NNRTI   Delavirdine (Rescriptor)    Common: headache, fatigue, nausea,
                                    vomiting, diarrhoea

        Nevirapine (Nevimune;       Common: sedative effects, headache,
        Viramune)                   nausea, diarrhoea

        Efavirenz (Stocrin)         Common: central nervous system
                                    (dizziness, etc.)

PI      Indinavir (Crixivan)        Common: nausea, headache,
                                    hyperbilirubinaemia
                                    Less common: hyperglycaemia

        Nelfinavir (Viracept)       Common: nausea, vomiting,
                                    diarrhoea, headache

                                    Less common: abdominal pain,
                                    hyperglycaemia

        Saquinavir (Invi-Rase)      Common: nausea, vomiting,
                                    diarrhoea, headache

                                    Less common: hyperglycaemia

        Saquinavir (Fortovase)      Common: nausea, vomiting,
                                    diarrhoea, headache

                                    Less common: hyperglycaemia

        Ritonavir (Norvir)          Common: nausea, vomiting,
                                    diarrhoea, anorexia

                                    Less common: increased serum
                                    triglyceride and cholesterol,
                                    hyperglycaemia

        Lopinavir/Rionavir          Common: nausea, vomiting,
        (Kaletra)                   diarrhoea, headache

                                    Less common: hyperglycaemia

        Amprenavir (Agenerase)      Common: headache, nausea, vomiting,
                                    diarrhoea

* Some of the abovementioned trade names are used internationally
and are included for reference when accessing international
literature.

Table III. Clinical aspects of the lipodystrophy syndrome

Fat accumulation

* Abdominal obesity
* Dorsocervical pad ('buffalo hump')
* Cervical hypertrophy
* Lipomas
* Breast enlargement

Fat loss

* Face wasting (reduction or absence of subcutaneous tissue on
  the cheeks with sparing of the facial musculature)
* Loss of subcutaneous fat of extremities
* Loss of gluteal mass

Biological abnormalities

* Glucose intolerance, diabetes, hyperinsulinaemia and
  increased insulin resistance
* Hypertriglyceridaemia
* Hypercholesterolaemia: increased LDL cholesterol, decreased
  HDL cholesterol

Table IV. Anthropometric variables that can be considered as
indicators of wasting status or manifestations of lipodystrophy,
or both

Variables related to

Wasting                                       Lipodystrophy

Body mass (BM)                                Waist-to-hip ratio (W:H)
Percentage of ideal body mass (%IBW)
Body mass index (BMI)
Percentage of ideal arm circumference (%IAC)
Upper arm fat area (UAFA) *                   Upper arm fat area (UAFA)
Upper arm muscle area (UAMA) *
Thigh skinfold
Thigh circumference
Fat mass index (FMI)
Lean body mass (LBM)
Fat-free mass index or LBM index (LBMI)

* Anthropometry calculations for measurements in mm:

UAMA = [[{upper arm circumference--([pi] x triceps skinfold)}.sup.2]]/
4[pi]

UAFA = [[pi]/4 x [(upper arm circumference/[pi]).sup.2]]--UAMA

Table V. South African HIV-positive women: Pilot study
of measurements taken just before initiation of ART

                                        Baseline pre-ART

Variable                            Mean [+ or -] SD     N

CD4+ count (cells/[micro]l)          118 [+ or -] 67     7
CDC immune category                    3 [+ or -] 0      7
Body mass (kg)                      56.1 [+ or -] 14.6   8
Body mass index (kg/[m.sup.2])      22.4 [+ or -] 6.4    7
Percentage of ideal body mass (%)    108 [+ or -] 33     7
Arm circumference (cm)              24.7 [+ or -] 5.3    8
Waist circumference (cm)            72.0 [+ or -] 7.8    8
Percentage of ideal arm
  circumference (%)                   87 [+ or -] 17     8
Hip circumference (cm)              94.5 [+ or -] 14.4   8
Waist-to-hip ratio                  0.77 [+ or -] 0.08   8