"I don't want to look like an AIDS victim": A New Zealand case study of facial lipoatrophy

The development of antiretroviral (ARV) drugs to treat HIV has turned what was once a death sentence into a chronic disorder. However, a focus on absence of disease in the form of an undetectable viral load and the dismissal of the so-called "cosmetic" complications of the disease ignores perceptions of health and well-being of those living with HIV. Facial lipoatrophy is a stigmatising side effect of treatment for HIV as it betrays the presence of the virus within the body. The study took a longitudinal qualitative approach, interviewing 11 people twice over a period of 1 year on their experience of living with HIV. Two participants were given cameras and asked to take photos which represented what it was like for them to live with this condition and were interviewed four times at four monthly intervals. This paper looks at one man's struggle to conceal or veil his facial lipoatrophy. His story is presented in the form of "selfies" and extracts from in-depth interviews. It tells of an emotional (ongoing) journey of frustration, anger, excitement, depression and resignation which had a profound effect on his sense of social and psychological well-being. This suggests a more holistic approach to treating people living with HIV is needed. While an undetectable viral load is indeed vital, it should not be seen as the only essential outcome of treatment.

[Lopinavir/ritonavir in human immunodeficiency virus-infected women]

There are clear sex-related biological differences between men and women. Diseases that affect the two sexes differently are studied separately. However, some diseases affect both men and women, but their incidence or outcome are clearly different. In human immunodeficiency virus infection, the potential differences in the effects of antiretroviral therapy are poorly characterized and few studies have been designed to elucidate these differences. Moreover, women are usually poorly represented in clinical trials of antiretroviral drugs.

Effects of raltegravir combined with tenofovir/emtricitabine on body shape, bone density, and lipids in African-Americans initiating HIV therapy

BACKGROUND

Raltegravir (RAL) plus tenofovir/emtricitabine (TDF/FTC) is a recommended initial antiretroviral regimen. A substantial proportion of persons diagnosed with HIV infection and starting antiretrovirals in the U.S. are African-American (AA); however, the effects of this regimen on metabolic parameters have largely been studied in white patients.

METHODS

Single-arm, open-label study of untreated AA HIV-infected patients administered RAL with TDF/FTC for 104 weeks. Changes in fasting lipids, insulin resistance, visceral adipose tissue (VAT), abdominal subcutaneous adipose tissue (SAT), limb and trunk fat, and bone mineral density (BMD) were assessed at weeks 56 and 104.

RESULTS

Thirty (85% men) participants were included. Median entry characteristics included age of 38 years, CD4 323 cells/mm3, HIV RNA level 29,245 copies/ml, and body mass index 28.1 kg/m2. At 56 and 104 weeks, significant increases in VAT, trunk fat, limb fat, and overall fat were observed. Bone mineral density decreased by 1.5% by week 104.There were no significant changes in non-HDL-cholesterol, fasting triglycerides, or insulin resistance. A median CD4 cell count increase of 318 cells/mm3 (IQR 179, 403; full range 40, 749) (P<0.001) was observed. Assuming missing=failure, 78 and 70% had HIV RNA levels<40 copies/ml at weeks 56 and 104, respectively. There were no treatment-related discontinuations and no new antiretroviral resistance mutations were detected.

CONCLUSIONS

In this cohort of AAs, initiation of RAL with TDF/FTC was associated with significant general increases in fat. Significant changes in lipids or insulin resistance were not observed and there was a small decline in BMD. Therapy was well tolerated and effective. These results are consistent with findings of studies of initial antiretroviral therapy in racially diverse cohorts and inform treatment selection for AA patients starting therapy for HIV infection.

Progression of Lipodystrophy (LD) with Continued Thymidine Analogue Usage: Long-Term Follow-Up from a Randomized Clinical Trial (The PIILR Study)

PURPOSE

During the 24-week PIILR study of protease inhibitor (PI) withdrawal, improved lipids and reduction in intraabdominal visceral fat was seen, however, there was also a loss of subcutaneous limb fat in patients with HIV-lipodystrophy (LD). It was hypothesized that overall improvement in LD may require a longer period of time off PIs.

METHOD

Follow-up of patients randomized to stop or continue PI-based therapy for 24 weeks, in a multicenter study, was continued for up to 120 weeks. Biochemistry and lipid parameters were assessed every 3 months. DEXA and CT scans were performed annually. Limb fat, visceral adipose tissue, and the lipodystrophy case definition score (LCDS) were used as indicators of LD severity.

RESULTS

Forty-five male patients with baseline and week 120 body composition data were assessed. There were no significant changes in the limb fat or visceral adipose tissue (VAT) components of LD, with the exception of the LCDS (change from baseline +5.79, p < .001). Control of viral replication was maintained and lipid and glycemic parameters were unchanged over the 120-week follow-up. Linear regression analysis showed on-study usage of stavudine was independently and significantly correlated with both decreased limb fat mass and a higher LCDS.

CONCLUSION

Body composition or metabolic features of LD did not improve over 2 years of observation in patients remaining on predominantly PI-sparing therapy. LD was adversely influenced by continued stavudine use.

Changes in Body Fat Measured by DEXA in Patients Taking Different Formulations of Stavudine

BACKGROUND

Lipoatrophy is a frequent complication of chronic stavudine therapy. Stavudine extended release formulation (stavudine ER) gives lower peak and higher trough levels than the immediate release formulation (stavudine IR), and we hypothesized that the lower peak might result in less lipoatrophy.

OBJECTIVE

To compare the rate of peripheral lipoatrophy between patients taking stavudine ER and stavudine IR.

METHOD

Body composition was measured by dual energy X-ray absorptiometry (DEXA) every 6 months for 18 months in 29 patients taking either stavudine ER or IR as part of a randomized controlled clinical trial.

RESULTS

DEXA fat measurements did not differ between the ER and IR groups at baseline, after a median of 32 months on stavudine-containing treatment. Over the 18 months of follow-up in the whole cohort limb fat decreased by a mean of 0.29 +/- 0.50 kg (p = .01) and leg fat percent decreased by a mean of 1.23% +/- 1.92% (p = .001), whereas trunk fat and trunk-to-limb fat percent ratio did not change significantly. There was no significant difference between the ER and IR groups in the rate of change of any of the fat parameters. At study completion, the proportion of patients with clinical lipodystrophy was similar in the stavudine ER and stavudine IR groups (67% and 64%, respectively; p = .893).

CONCLUSION

Stavudine ER does not appear to cause less peripheral lipoatrophy.

Worsening hypertriglyceridemia with oral contraceptive pills in an adolescent with HIV-associated lipodystrophy: a case report and review of the literature

Abstract We report a case of a 17-year-old girl with a history of congenital human immunodeficiency virus (HIV) infection and lipodystrophy secondary to highly active antiretroviral therapy (HAART). She developed severe worsening of preexisting hypertriglyceridemia after treatment with oral contraceptive pills (OCP) for polycystic ovary syndrome. Her hypertriglyceridemia improved upon OCP discontinuation. Although it is known that estrogen combined with progestins have a negative effect on triglycerides and high-density lipoprotein (HDL) cholesterol levels, to our knowledge the association of HAART-related lipodystrophy and severe hypertriglyceridemia after OCP use has not been reported in the literature. We recommend avoiding the use of OCPs in patients with lipodystrophy due to the increased risk of worsening hypertriglyceridemia.

Effects of switching to protease inhibitor monotherapy on nucleoside analogue-related adverse events

Switching from triple combination treatment to protease inhibitor monotherapy may increase the risk of elevations in HIV RNA, and is not recommended in most international treatment guidelines. However, the use of protease inhibitor monotherapy could prevent or reverse adverse events related to long-term use of nucleoside analogues, such as lipoatrophy, renal adverse events, osteopenia, and anemia. A detailed MEDLINE search was conducted to identify randomized clinical trials of triple-combination treatment versus protease inhibitor monotherapy with detailed analyses of safety. Summary results from analysis of changes in body composition, changes in lipids, renal adverse events, and anemia were evaluated for patients taking either protease inhibitor monotherapy or triple therapy. In six trials with dual-energy X-ray absorptiometry data available, the percentage of patients with lipoatrophy was significantly lower in the protease inhibitor monotherapy arms than the triple therapy arms (p = 0.03). In these trials there was also no significant difference in the risk of lipohypertrophy between protease inhibitor monotherapy and triple therapy arms. In one trial there was a higher risk of renal adverse events for patients taking tenofovir in the triple therapy arm. In two trials there were rises in total cholesterol when patients stopped taking tenofovir in the protease inhibitor monotherapy arms. In conclusion, there is a mixed pattern of changes in nucleoside analogue-related adverse events after switching from triple therapy to protease inhibitor therapy. The potential for safety benefits of stopping nucleoside analogues needs to be set against a higher risk of HIV RNA elevations during protease inhibitor monotherapy.

Alteration in pancreatic islet function in human immunodeficiency virus

Molecular mechanisms behind the defects in insulin production and secretion associated with antihuman immunodeficiency virus (anti-HIV) therapy and the development of HIV-associated lipodystrophy syndrome (HALS) are discussed in this article. Data suggesting insulin resistance on the beta cell and defects in first-phase insulin release of HALS patients are presented. Hepatic extraction of insulin, nonglucose insulin secretagogues and insulin-like growth factor release may exert influence on the demand of circulating insulin and on insulin secretion in HIV-infected patients. Finally, the paucity in understanding the incretin effects in HIV and HIV therapy in relation to insulin secretion is highlighted.

Kager's fat pad inflammation associated with HIV infection and AIDS: MRI findings

OBJECTIVE

To describe magnetic resonance imaging (MRI) features of Kager's fat pad inflammation in HIV-positive patients with lipodystrophy due to protease inhibitor treatment and posterior ankle pain.

METHODS

A case-control, cross-sectional study; group 1 included 14 HIV-positive patients using protease inhibitors, presenting lipodystrophy syndrome and having posterior ankle pain; group 2 (CGHIV-) included 112 HIV-negative patients without lipodystrophy syndrome who were being evaluated for posterior ankle pain; group 3 (CGHIV + 1) included 23 HIV-positive patients not using a protease inhibitor, without lipodystrophy syndrome and with posterior ankle pain; group 4 (CGHIV + 2) comprised 18 HIV-positive patients who were being treated with a protease inhibitor and had lipodystrophy syndrome but did not have posterior ankle pain. Images were evaluated for the presence of edema by two radiologists who were blinded to clinical features. Fisher's exact test was used to evaluate differences among the groups. Interobserver variation was tested using Cohen's kappa (κ) statistic.

RESULTS

The presence of edema within Kager's fat pad was strongly associated with symptoms in HIV-positive patients who had lipodystrophy (p ≤ 0.0001). Concordance between observers was excellent (κ > 0.9).

CONCLUSION

MRI findings of Kager's fat pad inflammation related to HIV/AIDS is a source of symptoms in HIV patients with posterior ankle pain using protease inhibitors and having lipodystrophy syndrome.

Prevalence of highly active antiretroviral therapy associated metabolic abnormalities and lipodystrophy in HIV infected patients

BACKGROUND

Highly active antiretroviral therapy (HAART) improves the longevity of HIV patients. However, the side effect of the drugs leads to development of chronic metabolic and cardiovascular complications.

OBJECTIVE

The aim of the study was to determine the prevalence and risk factors of the metabolic abnormalities and lipodystrophy among adult Ethiopian HIV infected patients on ART for one year and above.

METHODS

A cross-sectional study was conducted among HIV infected patients on HAART for one year or more, attending the ART clinics of Tikur Anbessa Specialized hospital in Addis Ababa. A total of consecutive 356 HIV infected patients volunteered to participate in the study from July 2007 to January 2008. Data was collected using clinical interview technique on structured questionnaires and physical examination of the patient, 319 had biochemical tests performed.

RESULTS

Three hundred fifty six HIV patients; 261 (73.1%) females and 95 (26%) males were studied. Two hundred nine (59.7%) patients were on Stavudine based and 135 (41.3%) were on Zidovudine based ART therapy. The overall prevalence of lipodystrophy was 68.3% (243), prevalence of hyperlipademia among 319 HIV patient was 56.9% Among these, the prevalence of hypercholesterolemia was 38.2%, high LDL cholesterol was 54.2% hypertryglyceredimeia was 15.2% Fasting hyperglycemia was 17.8% (IFG in 10.9% and overt diabetes in 6.9%). History of smoking was significantly associated with lipoatrophy and lipohypertrophy. ART regimen d4T was significantly associated with lipoatrophy. Duration of ART treatment > or = 1 yr was significantly associated with both lipoatrophy, lipohypertrophy and hypertriglyceredemia.

CONCLUSIONS AND RECOMMENDATIONS

Lipodystrophies occurred in majority of patients on ART treatment for longer than one year, hyperlipaedemia and hyperglycaemia were also seen commonly in Ethiopian HIV patients on HAART. We recommend careful monitoring of metabolic abnormalities, examination of the patient for early detection of the side effect, change of the offending agents management of metabolic abnormalities.

Fat redistribution syndromes associated with HIV-1 infection and combination antiretroviral therapy

More than 15 years after the introduction of highly active antiretroviral therapy, HIV/HAART-associated lipodystrophy syndrome still shadows the indisputable efficacy of antiretroviral therapy. Several issues related to this complication (prevalence, diagnosis, pathogenesis, prevention, or clinical management) have not been completely clarified. However, in the last years, substantial progress has been made in elucidating some of these basic aspects. This includes a better knowledge of the pathogenic mechanisms underlying HIV/HAART-associated lipodystrophy syndrome such as genetic host determinants, the impact of HIV infection per se, as well as the contribution of antiretroviral therapy. In regard to treatment, we have learned that certain drugs are especially prone to cause HIV/HAART-associated lipodystrophy syndrome (i.e. thymidine analogues). Pharmacological interventions to treat this condition have yielded mostly disappointing results, and the only intervention which offers an immediate aesthetical improvement for patients with HIV/HAART-associated lipodystrophy syndrome is plastic surgery. Even under the most favorable conditions (ideal host genetic make-up, and the timely initiation of HIV therapy with less toxic drugs), current data show that HIV/HAART-associated lipodystrophy syndrome is a complication of HIV infection and/or antiretroviral treatment that we are unable to avoid. In the context of HIV-1-infected patients under long-term antiretroviral therapy, fat toxicity is still the dark side of the rainbow.

Comparative transcriptional profiling in HIV-infected patients using human stress arrays: clues to metabolic syndrome

Highly active antiretroviral therapy (HAART therapy) for HIV-1 infection has significantly increased the survival and quality of life of patients with this disease. However, in several epidemiological studies the onset of metabolic syndrome is a phenomenon reported to be extremely frequent. In the present study, genes involved in the molecular cascade responsible for the alteration of fat tissue and of lipid and glucose metabolism in patients with HIV-1 infection treated with antiretroviral therapy were identified. Towards this goal, hybridization using Atlas cDNA Expression Arrays allowed simultaneous monitoring of the expression levels of approximately 250 genes and identification of a panel of changes in relation to different therapeutic groups and in the presence of metabolic syndrome, with some genes being up-regulated, while others are down-regulated in the different subgroups of patients. The results of this analysis have shown a panel of transcriptional changes associated with oxidative stress mechanisms that provide a basis for further studies on understanding of mechanisms that, in vivo, are the foundation the metabolic disorders in patients with HIV infection.

Suppression of pre adipocyte differentiation and promotion of adipocyte death by anti-HIV drugs

In the present study, we investigated the ability of anti-HIV drugs to interfere with normal cell cycle progression and to induce oxidative stress by perturbing the redox environment. Our results provide evidence that anti-HIV drugs have a differential effect on adipocyte cell cycle and differentiation, being able to modify the response to oxidative stress through an increase of reactive oxygen species (ROS) that compromises the induction of phase-2 and antioxidant enzymes. In detail, saquinavir, efavirenz, and stavudine exert antiadipogenic influences on the model 3T3-L1 cell line, perturbing the oxidative response and inducing of apoptosis. When considered together, the effects of anti-HIV drugs on 3T3-L1 pre adipocytes are distinct but commonly antiadipogenic, thus suggesting another additional possible mechanism by which antiretroviral therapies could contribute to lipoatrophy.

A facial marker in facial wasting rehabilitation

BACKGROUND

Facial lipoatrophy is one of the most distressing manifestation for HIV patients. It can be stigmatizing, severely affecting quality of life and self-esteem, and it may result in reduced antiretroviral adherence. Several filling techniques have been proposed in facial wasting restoration, with different outcomes. The aim of this study is to present a triangular area that is useful to fill in facial wasting rehabilitation.

METHODS

Twenty-eight HIV patients rehabilitated for facial wasting were enrolled in this study. Sixteen were rehabilitated with a non-resorbable filler and twelve with structural fat graft harvested from lipohypertrophied areas. A photographic pre-operative and post-operative evaluation was performed by the patients and by two plastic surgeons who were "blinded." The filled area, in both patients rehabilitated with structural fat grafts or non-resorbable filler, was a triangular area of depression identified between the nasolabial fold, the malar arch, and the line that connects these two anatomical landmarks.

RESULTS

The cosmetic result was evaluated after three months after the last filling procedure in the non-resorbable filler group and after three months post-surgery in the structural fat graft group. The mean patient satisfaction score was 8.7 as assessed with a visual analogue scale. The mean score for blinded evaluators was 7.6.

CONCLUSION

In this study the authors describe a triangular area of the face, between the nasolabial fold, the malar arch, and the line that connects these two anatomical landmarks, where a good aesthetic facial restoration in HIV patients with facial wasting may be achieved regardless of which filling technique is used.

What should we know about metabolic syndrome and lipodystrophy in AIDS?

OBJECTIVE

Prevalence of chronic complications of HIV infection is increasing and early recognition and treatment of the components of metabolic syndrome (MS) are essential to prevent cardiovascular and metabolic complications. Considering this, we performed a cross-sectional study on the prevalence and risk-factors for MS among HIV-infected subjects.

METHODS

A total of 819 patients followed at a large outpatient HIV unit were assessed by an interviewer-administered questionnaire that recorded several demographic, epidemiologic, clinical, laboratory, and social variables. Lipodystrophy diagnosis relied on agreement between patient's self-report and physician's observation of altered body-fat deposits. The presence of three or more of the following characteristics identified MS: increased waist circumference, hypertriglyceridemia, low HDL cholesterol level, hypertension, and hyperglycemia. We used logistic regression analyses to study variables independently associated with MS.

RESULTS

The prevalence of MS was 20.6% and that of lipodystrophy was 38.5%. 61 (36.1%) out of 169 patients with MS had also lipodystrophy. Patients with metabolic syndrome were significantly more likely to be older (OR = 1.08), had higher CD4 counts (OR = 1.001), had an increased body mass index (OR = 1.27) and had longer exposure to antiretroviral therapy (OR = 1.01) than those without metabolic syndrome.

CONCLUSION

Both traditional risk factors for cardiovascular disease and factors associated with HIV infection itself, such as an increased CD4 cell count and a longer exposure to antiretroviral therapy, seem to be associated with metabolic syndrome in the present study population.

Polyacrylamide gel treatment of antiretroviral therapy-induced facial lipoatrophy in HIV patients

BACKGROUND

Today, highly active antiretroviral therapy is lifesaving for most HIV-infected patients, but the treatment can result in facial lipoatrophy, which changes the face so radically that patients may develop severe psychological and social problems. Since 2001 polyacrylamide gel (PAAG) has been used successfully in HIV patients abroad. This article describes the results of a Danish study.

METHODS

Forty HIV patients recruited from two major referral hospitals in the capitol area of Copenhagen, Denmark, each received a series of PAAG gel injections (small deposits in several sessions) with a 14-day interval. Patient satisfaction, injector's evaluation, evaluation by an external specialist in plastic surgery, and long-term aesthetic effect and complications were registered with follow-up until 2 years.

RESULTS

All patients were very satisfied or satisfied with the result. The injector found the result very satisfying in 33 cases and a slight irregularity in 7. The external specialist found improvement in all cases with a one-grade reduction of the lipoatrophy in 11 cases, a two-grade reduction in 20, and a three-grade reduction in 3 cases. No filler-associated complications were recorded.

CONCLUSION

This study has shown that PAAG can normalize contours in patients suffering from facial lipoatrophy within 3-6 sessions, with a mean amount of gel per session of 1.8 ml and a mean total amount of 8.8 ml. The results are in accordance with those of other large studies, confirming a high degree of biocompatibility and safety.

Management of the metabolic effects of HIV and HIV drugs

Morphologic and metabolic abnormalities, including subcutaneous adipose tissue wasting, central adipose tissue accumulation, dyslipidemia and disorders of glucose metabolism are common among HIV-infected patients receiving highly active antiretroviral therapy (HAART) and contribute to the risk of cardiovascular disease in this population. The pathogenesis of these disorders is due to complicated interactions between effects of chronic HIV infection, HAART medications and patient factors, including genetic susceptibility. HAART has transformed HIV into a chronic condition for many patients and as a result the majority of HIV-infected patients in many areas of the developed world will soon be aged ≥50 years. Given that metabolic and cardiovascular diseases increase with aging, knowledge of the optimal management of these conditions is essential for practitioners caring for HIV-infected patients, including endocrine subspecialists. This Review highlights the clinical management of these disorders, focusing on the latest evidence regarding the efficacy of treatment strategies, newly available medications and potential interactions between HAART medications and medications used to treat metabolic disorders.

Comparison of dorsocervical with abdominal subcutaneous adipose tissue in patients with and without antiretroviral therapy-associated lipodystrophy

OBJECTIVE

Combination antiretroviral therapy (cART) is associated with lipodystrophy, i.e., loss of subcutaneous adipose tissue in the abdomen, limbs, and face and its accumulation intra-abdominally. No fat is lost dorsocervically and it can even accumulate in this region (buffalo hump). It is unknown how preserved dorsocervical fat differs from abdominal subcutaneous fat in HIV-1-infected cART-treated patients with (cART+LD+) and without (cART+LD-) lipodystrophy.

RESEARCH DESIGN AND METHODS

We used histology, microarray, PCR, and magnetic resonance imaging to compare dorsocervical and abdominal subcutaneous adipose tissue in cART+LD+ (n=21) and cART+LD- (n=11).

RESULTS

Albeit dorsocervical adipose tissue in cART+LD+ seems spared from lipoatrophy, its mitochondrial DNA (mtDNA; copies/cell) content was significantly lower (by 62%) than that of the corresponding tissue in cART+LD-. Expression of CD68 mRNA, a marker of macrophages, and numerous inflammatory genes in microarray were significantly lower in dorsocervical versus abdominal subcutaneous adipose tissue. Genes with the greatest difference in expression between the two depots were those involved in regulation of transcription and regionalization (homeobox genes), irrespective of lipodystrophy status. There was negligible mRNA expression of uncoupling protein 1, a gene characteristic of brown adipose tissue, in either depot.

CONCLUSIONS

Because mtDNA is depleted even in the nonatrophic dorsocervical adipose tissue, it is unlikely that the cause of lipoatrophy is loss of mtDNA. Dorsocervical adipose tissue is less inflamed than lipoatrophic adipose tissue. It does not resemble brown adipose tissue. The greatest difference in gene expression between dorsocervical and abdominal subcutaneous adipose tissue is in expression of homeobox genes.

Growth hormone and HIV infection: contribution to disease manifestations and clinical implications

In untreated HIV patients growth hormone deficiency contributes to loss of lean and fat mass. Pharmacologic doses of growth hormone successfully reverse this wasting process. In patients responding to antiretroviral therapies several non AIDS-related complications usually common among older, uninfected persons now occur more frequently in younger HIV patients. Among these conditions are cardiovascular disease and metabolic disorders. Although their etiology is multifactorial, changes in growth hormone biology reflecting relative growth hormone deficiency occur and may be involved. In these patients truncal obesity, and associated dyslipidemia and glucose homeostasis changes contribute to impaired quality of life and increased cardiovascular risk. Treatment with growth hormone and growth hormone releasing factor leads to short-term improvement of some of these abnormalities. This paper will review abnormalities of growth hormone biology and the use of growth hormone and growth hormone releasing factor as therapeutic agents in HIV patients.

[HIV lipodystrophy]

Combined antiretroviral therapy results in extraordinary decrease of morbidity and mortality of HIV-infected patients and in an essential change of the HIV/AIDS disease prognosis. However, long-term intake of antiretroviral medicaments is related to occurrence of metabolic and morphological abnormalities, of which some have been combined into a new syndrome--the so called HIV lipodystrophy. The HIV lipodystrophy syndrome covers metabolic and morphological changes. Metabolic changes include dyslipidaemia with hypercholesterolaemia and/or hypertriglyceridaemia, insulin resistance with hyperinsulinaemia and hyperlaktataemia. Morphological changes have the nature of lipoatrophia (loss of subcutaneous fat--on the cheeks, on extremities, on buttocks and marked prominence of surface veins) or lipohypertrophia (growth of fat tissue--on the chest, in the dorsocervical area, lipomatosis of visceral tissues and organs, fat accumulation in the abdominal area). Several HIV lipodystrophy features are very similar to the metabolic syndrome of the general population. That is why this new syndrome represents a prospective risk of premature atherosclerosis and increase of the cardiovascular risk in young HIV positive individuals. The article mentions major presented studies dealing with the relation of antiretroviral treatment and the cardiovascular risk. The conclusions of the studies are not unequivocal--this is, among others, given by the reason that their length is short from the viewpoint of atherogenesis. The major risk of subclinical atherosclerosis acceleration seems to be related to the deep immunodeficiency and low number of CD4+ lymphocytes and florid, uncontrolled HIV infection with a high number of HIV-1 RNA copies actually circulating in the plasma. The question, whether metabolic and morphological changes related to HIV and cART carry a similar atherogenic potential as in the general population, remains open for future.

Uridine metabolism in HIV-1-infected patients: effect of infection, of antiretroviral therapy and of HIV-1/ART-associated lipodystrophy syndrome

Background

Uridine has been advocated for the treatment of HIV-1/HAART-associated lipodystrophy (HALS), although its metabolism in HIV-1-infected patients is poorly understood.

Methods

Plasma uridine concentrations were measured in 35 controls and 221 HIV-1-infected patients and fat uridine in 15 controls and 19 patients. The diagnosis of HALS was performed following the criteria of the Lipodystrophy Severity Grading Scale. Uridine was measured by a binary gradient-elution HPLC method. Analysis of genes encoding uridine metabolizing enzymes in fat was performed with TaqMan RT-PCR.

Results

Median plasma uridine concentrations for HIV-1-infected patients were 3.80 µmol/l (interquartile range: 1.60), and for controls 4.60 µmol/l (IQR: 1.8) (P = 0.0009). In fat, they were of 6.0 (3.67), and 2.8 (4.65) nmol/mg of protein, respectively (P = 0.0118). Patients with a mixed HALS form had a median plasma uridine level of 4.0 (IC95%: 3.40–4.80) whereas in those with isolated lipoatrophy it was 3.25 (2.55–4.15) µmol/l/l (P = 0.0066). The expression of uridine cytidine kinase and uridine phosphorylase genes was significantly decreased in all groups of patients with respect to controls. A higher expression of the mRNAs for concentrative nucleoside transporters was found in HIV-1-infected patients with respect to healthy controls.

Conclusions

HIV-1 infection is associated with a decrease in plasma uridine and a shift of uridine to the adipose tissue compartment. Antiretroviral therapy was not associated with plasma uridine concentrations, but pure lipoatrophic HALS was associated with significantly lower plasma uridine concentrations.

Cutaneous toxicities of antiretroviral therapy for HIV: part I. Lipodystrophy syndrome, nucleoside reverse transcriptase inhibitors, and protease inhibitors

Antiretroviral medications for the treatment of HIV are common drugs with diverse and frequent skin manifestations. Multiple new cutaneous effects have been recognized in the past decade. Dermatologists play an important role in accurately diagnosing and managing the cutaneous toxicities of these medications, thereby ensuring that a patient has as many therapeutic options as possible for life-long viral suppression. Part I of this two-part series on the cutaneous adverse effects of antiretroviral medications will discuss HIV-associated lipodystrophy syndrome, which can be seen as a result of many antiretroviral medications for HIV, and the specific cutaneous effects of the nucleoside reverse transcriptase inhibitors and protease inhibitors.

Regional adipose tissue measured by MRI over 5 years in HIV-infected and control participants indicates persistence of HIV-associated lipoatrophy

OBJECTIVE

Peripheral fat loss and visceral fat gain have been reported in HIV infection. There are limited data on long-term change in adipose tissue in HIV-infected patients vs. controls. Therefore, we determined change in regional adipose tissue from baseline examination to 5 years later among participants in the study of Fat Redistribution and Metabolic Change in HIV Infection.

METHODS

Regional adipose tissue volume was measured using MRI at both examinations in 477 HIV-infected and 214 control men and women. Lipoatrophy was defined as leg subcutaneous adipose tissue (SAT) below the cutoff point marking the lowest decile (10%) of controls at each examination.

RESULTS

HIV-infected and control participants showed similar adipose tissue gains. In men, all SAT depots and visceral adipose tissue started lower and remained lower on average in HIV-infected vs. controls. In women, leg and arm SAT also started lower and remained lower in HIV-infected vs. controls. Mean leg SAT of HIV-infected men was 67% of control men at baseline and 65% at follow-up; for women 83% and 77%. At baseline, 48% of HIV-infected participants had lipoatrophy; on average those with baseline lipoatrophy gained 0.96L of leg SAT compared with 1.23L gain for controls in the lowest decile (P = 0.16). At follow-up, 53% of HIV-infected participants had lipoatrophy. In multivariable models, discontinuation of stavudine appeared to produce little gain in leg SAT ( approximately 1.1%/year).

CONCLUSION

HIV-infected participants did not substantially recover SAT compared with controls, although both showed average gains. HIV-associated lipoatrophy persisted after 5 years of follow-up.

Morphologic and body composition changes are different in men and women on generic combination antiretroviral therapy--an observational study

BACKGROUND

Increasingly effective therapies for HIV infection, combination antiretroviral therapy, are now widely available in developing countries. A range of metabolic complications presenting as abnormalities of body-fat mass distribution in association with dyslipidemia and glucose homeostasis dysregulation, have been recognized as important toxicities in patients treated with these drugs. With increasing use of antiretroviral therapy in India, we examined the association between gender and body shape and composition, one year after initiating combination antiretroviral therapy and attempted to identify simple clinical markers to detect and monitor these changes.

METHODS

Patients on combination antiretroviral therapy (2 NRTIs + 1 NNRTI), attending a HIV clinic between July 2005 and December 2006 had anthropometry clinical examination and bioelectric impedance analysis (BIA) performed along with blood tests at baseline and after 1 year.

RESULTS

Of the 34 patients on combination antiretroviral therapy, 5 males and 12 females had noticeable changes in their body shape. Significant decrease in triceps skin fold thickness, an increase in waist circumference and waist: hip ratio was observed in females. BIA did not show any change in total body fat in either sex.

CONCLUSIONS

Since the presence and severity of fat redistribution could affect adherence as well as the success of antiretroviral therapy, close monitoring is required to detect and prevent this complication early.

Rosiglitazone improves lipoatrophy in patients receiving thymidine-sparing regimens

OBJECTIVE

Thymidine reverse transcriptase inhibitors (tNRTI) are strong inhibitors of PPAR-gamma and clearly implicated as a cause of lipoatrophy. Thiazolidenediaones (TZD), potent PPAR-gamma agonists, would be expected to be beneficial in HIV lipoatrophy, but prior studies have been conflicting. None specifically excluded the use of tNRTIs. We report the first study in individuals treated with tNRTI-sparing regimens using a TZD for treatment of HIV lipoatrophy.

DESIGN

This double-blind, placebo-controlled study evaluated limb fat in HIV-infected individuals with lipoatrophy who discontinued tNRTI at least 24 weeks prior to enrollment.

METHODS

Individuals were randomized to rosiglitazone vs. placebo for 48 weeks. Dual energy X-ray absorptiometry (DEXA)-scans and fasting metabolic assessments were serially performed.

RESULTS

We enrolled 71 individuals, 17% were female and 51% white. Baseline characteristics were similar between groups except for higher total cholesterol in the placebo group (P = 0.04). At 48 weeks, limb fat (grams) increased significantly (P = 0.02) more in the rosiglitazone than in the placebo group: median (IQR) 448 (138, 1670) vs. 153 (-100, 682), respectively. Of lipids parameters, only total cholesterol increased significantly more in the rosiglitazone group (P = 0.008). Prevalence of metabolic syndrome and total bone mineral density did not change between or within groups.

CONCLUSION

In the absence of tNRTI, rosiglitazone significantly improves lipoatrophy without deleterious effect on bone mineral density. Total cholesterol, but not triglycerides, significantly increased in the rosiglitazone arm. The glitazones may be a promising addition for accelerating fat recovery in individuals who had switched off tNRTI and remain with significant lipoatrophy.

[Lipodystrophy and metabolic disturbances as complications of antiretroviral therapy]

Effective treatment of HIV infection with antiretroviral drugs significantly improve prognosis. Reduction of mortality and life prolongations in patients receiving such therapy have been also connected with the risk of side effects development. Among these complications metabolic disturbances such as lipodystrophy, dyslipidaemia, and insulin resistance which are present according some authors in up to 50% of patients receiving HAART play an important role. In spite of different investigations molecular basis of lipodystrophy development during HAART have not be fully understood, and the latest research revealed a lot of new aspects connected w adipocyte tissue pathophysiology, which were not taken up to know into consideration. In the presented publication the most important information about pathogenesis of lipodystrophy development in HIV infected patients treated with ARV drugs have been presented.

Impact of switching antiretroviral therapy on lipodystrophy and other metabolic complications: a review

Following the introduction of highly active antiretroviral therapy (HAART), metabolic and morphological complications known as HIV associated lipodystrophy syndrome (HALS) have been increasingly common. The approaches to target these complications span from resistance exercise, diet and use of the antidiabetics metformin or glitazones to high dose recombinant human growth hormone therapy or switching antiretroviral regimen. When looking at the effect of switching therapy, focus has been addressed to protease inhibitor (PI) based regimens, as PI was the first component of HAART recognized to be correlated with the disfiguring body-alterations known as HALS. More recently, however, regimens containing nucleoside reverse-transcriptase inhibitors (NRTI) have attracted attention. Reviewing switch studies regarding metabolic parameters and body shape changes, certain trends emerge. Switching from PI, the metabolic complications such as dyslipidaemia and insulin resistance seem to be partly reversible, whereas the morphologic alterations appear to be unchanged. In studies in which NRTI's are switched, dyslipidaemia appears unaffected, but a modest improvement in peripheral lipoatrophy has been reported. However the results are often inconsistent and difficult to interpret, mostly because of limitations in study design, patient number and duration of follow-up. The need for larger, controlled, randomized, long-term studies is evident.

Disorders of body fat distribution in HIV-1-infected patients

Body fat disorders are a common and relevant problem in HIV-1-infected patients that can be associated with metabolic alterations. Many controversies in their definition, pathogenesis, measurement, and management remain unclear. Several factors including HIV-1 infection itself and antiretroviral therapy have been associated with the development of these alterations. Most studies show that the action of drugs on the pathogenesis of lipoatrophy is undeniable. However, they also show that there are considerable differences not only between the different families of antiretroviral drugs, but also between the individual members of these families. The diagnosis of lipodystrophy is limited by the absence of an agreed definition and a reference for normality. Accurate diagnosis, especially in mild-moderate cases, is difficult, almost always subjective, not standardized, and cannot be carried out by a single method. In general, subjective evaluation by the physician and patient, together with simple techniques such as anthropometry, can provide highly valuable information, especially when used over time. Although there is no known therapy to completely reverse lipodystrophy once it becomes established, there is evidence that lipoatrophy can be partially improved by replacing thymidine analogs in certain cases. In addition, reparative surgery may prove useful in moderate or severe cases. Neither the interruption of antiretroviral therapy nor the use of metformin, glitazones or growth hormone analogs can be recommended due to their limited efficacy or associated complications.

Treatment of facial lipoatrophy via autologous fat transfer

The advent of highly active anti-retroviral therapy (HAART) has extended the lives of patients affected by human immunodeficiency virus (HIV) disease. A common cutaneous side effect of HAART is facial lipoatrophy. The hollowed out cheeks, temples and eye sockets often lead to a gaunt cachetic facies which can be a disconcerting stigmata of the disease and a psychological burden to the patient. Autologous fat transfer (ATF) is a minimally invasive surgical procedure that can temporarily improve the appearance in patients with facial lipoatrophy. Other corrective procedures (e.g., injectable fillers) are available, but, to date, the ideal procedure for permanent correction of facial lipoatrophy has not been found.

HIV or HIV-therapy? Causal attributions of symptoms and their impact on treatment decisions among women and men with HIV

OBJECTIVES

Among people with HIV, we examined symptom attribution to HIV or HIV-therapy, awareness of potential side effects and discontinuation of treatment, as well as sex/gender differences.

METHODS

HIV-patients (N=168, 46% female) completed a comprehensive symptom checklist (attributing each endorsed symptom to HIV, HIV-therapy, or other causes), reported reasons for treatment discontinuations and potential ART-related laboratory abnormalities.

RESULTS

Main symptom areas were fatigue/sleep/energy, depression/mood, lipodystrophy, and gastrointestinal, dermatological, and neurological problems. Top HIV-attributed symptoms were lack of stamina/energy in both genders, night sweats, depression, mood swings in women; and fatigue, lethargy, difficulties concentrating in men. Women attributed symptoms less frequently to HIV than men, particularly fatigue (p<.01). Top treatment-attributed symptoms were lipodystrophy and gastrointestinal problems in both genders. Symptom attribution to HIV-therapy did not differ between genders. Over the past six months, 22% switched/interrupted ART due to side effects. In women, side effect-related treatment decisions were more complex, involving more side effects and substances. Remarkably, women took predominantly protease inhibitor-sparing regimens (p=.05). Both genders reported only 15% of potential ART-related laboratory abnormalities but more than 50% had laboratory abnormalities. Notably, women had fewer elevated renal parameters (p<.01).

CONCLUSIONS

Men may attribute symptoms more often to HIV and maintain a treatment-regimen despite side effects, whereas women may be more prudent in avoiding treatment side effects. Lacking awareness of laboratory abnormalities in both genders potentially indicates gaps in physician-patient communication. Gender differences in causal attributions of symptoms/side effects may influence treatment decisions.

High molecular weight form of adiponectin in antiretroviral drug-induced dyslipidemia in HIV-infected Japanese individuals based on in vivo and in vitro analyses

OBJECTIVE

High molecular weight (HMW)-adiponectin has been found to be a better negative regulator of insulin resistance than total adiponectin. The aim of this study was to investigate the influence of HMW-adiponectin on antiretroviral therapy (ART)-induced dyslipidemia in Japanese human immunodeficiency virus (HIV)-infected individuals. We also examined the effect of some antiretroviral drugs (ARVs) on adipocytes in vitro.

PATIENTS AND METHODS

Fifty-seven HIV-infected patients were enrolled in four clinical groups; (I) patients who started ART containing efavirenz (EFV); (II) patients who started ART containing a protease inhibitor without atazanavir (ATV); (III) patients who started ART containing ATV; (IV) patients who switched from ART without ATV into ART containing ATV. We measured the serum HMW-adiponectin before and one year after starting or changing ART, using an enzyme-linked immunoSorbent assay (ELISA). Furthermore, we treated the mouse adipocytes (3T3-L1) with some ARVs. The lipid content was assessed using Oil Red O staining. The expression of adiponectin was measured by quantitative real-time PCR.

RESULTS

The serum HMW-adiponectin decreased significantly in groups (I) and (II) after starting ART, and increased significantly in group (IV) after changing from ART without ATV to ART with ART. EFV, ritonavir (RTV) and nelfinavir (NFV) inhibited the expression of adiponectin mRNA in mature 3T3-L1 and to a greater extent in pre-mature 3T3-L1. This phenomenon was reversible when ARV was changed to ATV.

CONCLUSION

Effects of the ARVs on adiponectin may vary depending on the administration of different drugs. These data suggest that the distinct metabolic effects of ARV could therefore be a consequence of their differential effects on the production of adiponectin.

GH/GHRH axis in HIV lipodystrophy

Approximately half of patients with HIV-infection develop abnormal body fat distribution, characterized by increased abdominal, breast, and dorsocervical adiposity and decreased fat in the limbs and face in association with antiretroviral therapy. Changes in fat distribution are associated with dyslipidemia, insulin resistance, and increased cardiovascular risk in patients with HIV lipodystrophy. Growth hormone secretion is reduced and responses to standardized stimulation testing altered, suggesting relative growth hormone deficiency in this population. Growth hormone secretion is characterized by normal pulse frequency, but decreased pulse amplitude, pulse width, and trough GH levels compared to weight matched, non-HIV-infected patients. Abnormalities in GH secretion are strongly associated with body composition and metabolic abnormalities in patients with HIV lipodystrophy, particularly with increased visceral fat and elevated free fatty acids. Increased somatostatin tone and decreased ghrelin concentrations may also contribute to reduced GH levels. Administration of exogenous GH or growth hormone releasing hormone (GHRH) to normalize growth hormone concentrations is effective to reduce visceral fat and improve lipid parameters in HIV-infected patients. Treatment with supraphysiologic GH is limited by side effects and exacerbation of insulin resistance, whereas administration of physiologic doses of GH demonstrates more modest treatment effects but fewer adverse effects. Initial studies of GHRH also show significant reductions in visceral adipose tissue (VAT) with potentially fewer adverse effects. GHRH may be particularly useful to normalize GH dynamics in patients with HIV lipodystrophy by increasing endogenous GH pulse height, GH pulse width, and trough GH levels, while preserving the negative feedback of IGF-I on pituitary GH secretion.

Poly-L-lactic acid injection for HIV-associated facial lipoatrophy: treatment principles, case studies, and literature review

BACKGROUND

Most HIV-positive patients receiving highly active antiretroviral therapy develop facial lipoatrophy soon after commencing treatment. Attempts to correct lipoatrophy through autologous fat transfer or the use of temporary, semipermanent, or permanent fillers have achieved some benefits, but either do not have lasting effects, do not treat some areas effectively, or have other disadvantages.

OBJECTIVE

The purpose of this article is to outline the treatment principles for use of poly-L-lactic acid (PLLA) in HIV-associated facial lipoatrophy since its emergence in 1999 and review the relevant literature, with particular emphasis on investigations of the incidence of subcutaneous papule formation after PLLA treatment.

METHODS

The principles of treating facial lipoatrophy with PLLA, including product preparation, patient preparation, and injection technique, are reviewed. Two case studies and results are presented as typical examples of treatment and results. A literature discussion focuses on changes in the incidence of papule formation after PLLA treatment.

RESULTS

In the representative cases presented, 2 white men in their forties with facial lipoatrophy who had been HIV-positive for more than 10 years received 2 vials of PLLA in each of 5 treatments spaced 4 weeks apart. Results are shown 4 weeks after the final treatment. No papules were reported in the 12-month follow-up period.

CONCLUSIONS

Early investigations of PLLA for the treatment of HIV-associated facial lipoatrophy reported a significantly high incidence of subcutaneous papule formation. As experience with PLLA has increased, the incidence of papule formation has dropped dramatically. The proper dilution, adequate hydration time, proper placement of the product, sufficient intervals between treatments, and posttreatment massage all have contributed to this decrease.

Lipodystrophy in the patient with HIV: social, psychological, and treatment considerations

Approximately 1.3 million people in the United States and an estimated 33.2 million worldwide are infected with HIV. In the past, HIV/AIDS was considered to be uniformly fatal. With the introduction of highly active antiretroviral therapy (HAART), HIV has become a chronic, manageable disease in countries that are able to provide this therapy. The preservation of lives has not been without complications. In these patients, metabolic and stereotypical body disfiguring fat changes have emerged and have been lumped under the term lipodystrophy. Lipoatrophy and fat accumulation are generally thought to be separate yet overlapping phenomena. The prevalence rates for lipoatrophy may be as high as 25% to 38%; estimates for fat accumulation vary widely (from 14%-63%). Far from being "purely cosmetic," these fat changes can have a profoundly negative social and psychological impact, causing patients to feel disfigured, isolated, and stigmatized. Further, lipodystrophy may also negatively impact compliance with HAART. While there is evidence that the use of new HIV medications can prevent the development of these fat changes, many patients already manifest fat abnormalities; switching HAART, especially after lipodystrophy has progressed, offers only limited benefit. In addition, many resource-poor nations continue to rely on older HAART out of necessity. Because of this, methods are needed to address disfiguring body shape changes. The authors review the prevalence of lipoatrophy and lipohypertrophy, focusing on the impact on patients as well as reviewing available treatment options.

Antiretroviral therapy and the human immunodeficiency virus--improved survival but at what cost?

Patients infected with human immunodeficiency virus are living longer since the introduction of combination antiretroviral therapy more than a decade ago - but at what cost? Highly active antiretroviral therapy has been associated with lipodystrophy and associated metabolic derangements such as dyslipidaemia, insulin resistance and diabetes. These complications are likely to contribute to an increased risk of premature and accelerated atherosclerosis with growing concern about potential cardiovascular consequences.

[Corporal fat distribution and lipidic and glicemic profiles of HIV-infected patients]

The aims of this study were to describe anthropometric data and glycemic and lipidic profiles of HIV-infected patients treated or not with antiretrovirals (ARV) drugs, and to assess association between these drugs and body composition changes, lipid and glucose homeostasis disturbances. There were 176 patients included (133 ARV-treated patients and 43 ARV-naïve). The patients were submitted to clinical evaluation, laboratorial analysis, ultrasonographic measurements, bioelectrical impedance analysis and skin folds thickness measurements. The ARV-treated group showed higher waist-to-hip ratio (p= 0.0002), higher intra-abdominal fat thickness measured by ultrasonography (p= 0.003) and lower bicipital (p= 0.01) and tricipital (p= 0.0002) skin folds. This group also showed higher triglyceride (p= 0.0002), total cholesterol (p= 0.00007), HDL cholesterol (p= 0.009), glucose measurements one hour (p= 0.01) and two hours (p= 0.001) after dextrose load, higher levels of fasting insulin (p= 0.03) and higher HOMAR index (p= 0.02). The antiretroviral drugs are associated with increased visceral fat and decreased peripheral fat pads. Beside that, these drugs are associated with atherogenic lipid profile and insulin resistance, two independent risk predictors of cardiovascular disease.

Impact of lipoatrophy on patient-reported outcomes in antiretroviral-experienced patients

Lipoatrophy is a noteworthy adverse effect of antiretroviral therapy. A 2-part literature review was conducted to assess the impact of lipoatrophy in HIV-infected persons: the first reviewed the qualitative studies that reported lipoatrophy data, and the second reviewed the clinical studies that recorded patient-reported outcome end points. This literature review provided considerable evidence that lipoatrophy has a negative impact on the psychosocial well-being and health-related quality of life of HIV-infected persons receiving antiretroviral therapy. However, the patient-reported outcome measures used in clinical studies were not lipoatrophy-specific and had limited ability to show real changes in health status associated with lipoatrophy.

Reduced adipogenic gene expression in thigh adipose tissue precedes human immunodeficiency virus-associated lipoatrophy

CONTEXT

The expression of adipogenic genes in sc adipose tissue has been reported to be lower among patients with HIV-associated lipoatrophy than HIV-uninfected controls. It is unclear whether this is a result or cause of lipoatrophy.

OBJECTIVE

The objective of the study was to investigate the temporal relationships among changes in adipogenic gene expression in sc adipose tissue and changes in body fat distribution and metabolic complications in HIV-infected subjects on antiretroviral therapy.

DESIGN

This was a prospective longitudinal study.

SETTING

The study was conducted at HIV clinics in Seattle, Washington.

PARTICIPANTS

The study population included 31 HIV-infected and 12 control subjects.

INTERVENTIONS

Subjects were followed up for 12 months after they initiated or modified their existing antiretroviral regimen.

MAIN OUTCOME MEASURES

Changes in body composition, plasma lipids, insulin sensitivity, and gene expression in sc abdominal and thigh adipose tissue.

RESULTS

Subjects who developed lipoatrophy (n=10) had elevated fasting triglycerides [3.16 (sd 2.79) mmol/liter] and reduced insulin sensitivity as measured by frequently sampled iv glucose tolerance test [1.89 (sd 1.27)x10(-4) min(-1)/microU.ml] after 12 months, whereas those without lipoatrophy (n=21) did not show any metabolic complications [triglycerides 1.32 (sd 0.58) mmol/liter, P=0.01 vs. lipoatrophy; insulin sensitivity 3.52 (sd 1.91)x10(-4) min(-1)/microU.ml, P=0.01 vs. lipoatrophy]. In subjects developing lipoatrophy, the expression of genes involved in adipocyte differentiation, lipid uptake, and local cortisol production in thigh adipose tissue was significantly reduced already at the 2-month visit, several months before any loss of extremity fat mass was evident.

CONCLUSIONS

In HIV-infected subjects, lipoatrophy is associated with elevated fasting triglycerides and insulin resistance and might be caused by a direct or indirect effect of antiretroviral drugs on sc adipocyte differentiation.

Moving beyond biomedical understanding of lipodystrophy in people living with HIV/AIDS

The purpose of this article is to move beyond the biomedical standpoint in the field of HIV/AIDS in order to contribute to the recognition oflipodystrophy as a phenomenon that reaches far beyond its current definition as an unfortunate side effect of highly active antiretroviral therapy (HAART). This article hopes to demonstrate how theory, while remote to the clinical setting, can allow nurses to understand the experience of lipodystrophy as a social phenomenon and address it likewise in their practice. The specific aim of this article is to apply the concept of stigma to the experience of lipodystrophy in people living with HIV/AIDS. The objective of this theoretical piece is to fill the gaps in the way nurses address lipodystrophy in the clinical setting and to demonstrate the richness of Goffman's concept of stigma (1963) in understanding the experience of lipodystrophy.

Mitochondrial RNA and DNA alterations in HIV lipoatrophy are linked to antiretroviral therapy and not to HIV infection

BACKGROUND

The aim of this study was to assess the effect of antiretroviral therapy (ART) versus HIV on mitochondria in fat.

METHODS

Subcutaneous fat was collected from 45 HIV-infected patients on ART with lipoatrophy, 11 HIV-infected ART-naive patients and nine healthy controls. Three mitochondrial transcripts: NADH dehydrogenase subunit 1 (ND1), cytochrome B (CYTB) and NADH dehydrogenase subunit 6 (ND6) genes were quantitated using TaqMan probes and normalized to nuclear-encoded ribosomal L13.

RESULTS

ND1/L13 and CYTB/L13 were lower in HIV-positive patients on ART with lipoatrophy versus ART-naive patients (3.4 versus 7.2 [P=0.017] and 2.5 versus 4.6 [P=0.006], respectively). No difference was found between ART-naive patients and controls (P>0.70). ND6/L13 was similar between all groups. Dual-energy X-ray absorptiometry-measured limb fat and mitochondrial DNA in fat were also lower in HIV-positive patients on ART with lipoatrophy versus HIV-infected, ART-naive patients (4,382 versus 7,662 g [P=0.02] and 726 versus 1,372 copies/cell [P=0.03], respectively), but no difference was found between ART-naive and controls. In a multiple regression analysis, limb fat correlated with all three mitochrondrial RNA, whereas mitochondrial DNA did not correlate with mitochondrial RNA or limb fat.

CONCLUSIONS

In contrast to ART-naive patients, HIV-positive patients on ART with lipoatrophy had significant depletion in mitochondrial DNA in fat and mitochondrial RNAs. This suggests that mitochondrial toxicity in lipoatrophy could be driven by ART and not by HIV itself. In addition, mitochondrial RNA abnormalities, and not mitochondrial DNA depletion, could be a key driving force behind lipoatrophy.