Strategies for treating HIV-related lipodystrophy

A longitudinal evaluation of the impact of a polylactic acid injection therapy on health related quality of life amongst HIV patients treated with anti-retroviral agents under real conditions of use

Background

Many HIV patients receiving antiretroviral treatment develop lipodystrophy. NEW-FILL^® is a polylactic acid injected to treat facial lipoatrophy. The objectives of this study were to describe (1) change in quality of life (QoL) of HIV patients treated with NEW-FILL^® in the management of facial lipoatrophy; (2) efficacy of NEW-FILL^® using facial photographs and (3) a patient-reported “Overall Treatment Effect” (OTE) scale; and (4) safety of NEW-FILL^®.

Methods

Doctors from 13 treatment centres recruited 230 HIV patients to receive up to 5 sessions of NEW-FILL^® injections. Patients self-reported QoL with the ABCD questionnaire before the first set of injections, at 2 months and at 12 to 18 months after the last session of injections. Efficacy was evaluated at each interval through photographs and OTE scale. Safety was evaluated via Case Report Form (CRF) data.

Results

64.4% of patients reported QoL improvements of >10% at 2 months, and 58.8% at 12–18 months. Lipoatrophy grades improved at each visit (“no lipoatrophy” or “limited lipoatrophy”: 20.3% at inclusion, 77.4% at 2 months, 58.4% at 12–18 months). Average OTE scores of 5.3 and 5.0 at 2 and 12–18 months indicated “moderate improvement”. Minimum Important Difference (MID) in QoL score was 7.1 points at 2 months; 7.4 points at 12–18 months. For 911 injection sessions performed, 3.4% resulted in “immediate” adverse events, 7% in “non-immediate” events, and 1.7% in “other” events.

Conclusions

Improvements to quality of life and diminished lipoatrophy visibility were observed in the months immediately following NEW-FILL^® treatment and were maintained 12–18 months post-treatment. Most adverse events were mild and transient. ABCD MID thresholds provide clinicians with means to assess the impact of lipoatrophy therapies on QoL.

Nd:YAG laser-assisted liposuction for an HIV patient

Active antiretroviral therapy has reduced the mortality of patients with acquired immune deficiency syndrome (AIDS) and increased both the quality of life and the longevity of patients infected with human immunodeficiency virus (HIV). The long-term effects of HIV infection are increasingly observed, particularly changes in fat distribution or "lipodystrophy." Strategies to prevent, mitigate, or reverse HIV-associated lipodystrophy have been difficult to develop. The medical management of fat redistribution usually is ineffective, and surgical approaches to HIV-associated lipodystrophy have already been described, but major drawbacks include recurrence of the fat accumulation. This report aims to describe the clinical outcomes for a man with buffalo hump who underwent lipolaser-assisted liposuction. This technique obtained a significant reduction in the size of the adiposity and an improvement in the neck's range of motion. At this writing, after 3 years, the patient is satisfied with his cosmetic and functional results. The authors believe that lipolaser-assisted liposuction using the Smartlipo Deka-Mela neodymium:yttrium-aluminum-garnet (Nd:YAG) 1,064-mm-long pulse is effective in reducing the cervicodorsal fat pad. The technique is performed using local anesthesia with low operative risks and minimal surgical trauma. The treated zone shows rapid healing, and the whole procedure requires a day-hospital recovery, thus reducing the costs.

Bio‐AlcamidTMin drug‐induced lipodystrophy

The development of new drugs to counter human immunodeficiency virus (HIV) infection has led to an increase in lipodystrophic syndrome among HIV-infected individuals receiving combination therapy. Bio-Alcamid(TM) is a recently developed polymeric substance that can be implanted to compensate for adipose effects. We have implanted this substance in 73 patients with up to three years' follow-up. The aesthetic results were deemed excellent by both physicians and patients. No implant dislocation, implant migration, granuloma, allergic reaction or intolerance were recorded.

HIV-associated adipose redistribution syndrome (HARS): definition, epidemiology and clinical impact

A segment of the HIV infected population develops abnormal and excessive accumulation of adipose tissue in the trunk, including accumulation of visceral (deep abdominal) adipose tissue. This condition, known as HIV-related adipose redistribution syndrome (HARS), may also be accompanied by fat accumulation in the upper back/neck (dorsocervical region) and/or depletion of subcutaneous adipose tissue from the abdomen, face, limbs, or buttocks. HARS is estimated to occur in up to 32% of patients and is associated with health risks similar to those of metabolic syndrome. Techniques to detect and measure HARS include physician and patient assessments and radiologic or anthropometric methods.

HIV-associated adipose redistribution syndrome (HARS): etiology and pathophysiological mechanisms

Human immunodeficiency virus (HIV)-associated adipose redistribution syndrome (HARS) is a fat accumulation disorder characterized by increases in visceral adipose tissue. Patients with HARS may also present with excess truncal fat and accumulation of dorsocervical fat ("buffalo hump"). The pathophysiology of HARS appears multifactorial and is not fully understood at present. Key pathophysiological influences include adipocyte dysfunction and an excessive free fatty acid release by adipocyte lipolysis. The contributory roles of free fatty acids, cytokines, hormones including cortisol, insulin and the growth hormone-adipocyte axis are significant. Other potential humoral, paracrine, endocrine, and neural influences are also discussed.

Sculptra: the New Three-Dimensional Filler

Sculptra, the synthetic injectable poly-l-lactic acid (PLLA), is a revolutionary three-dimensional filler lasting 18 to 24 months. This unique volumizing agent is best used to globally restore volume to the lower two thirds of the face in patients who have lipoatrophy. Sculptra is a biocompatible, biodegradable, and nonimmunogenic derivative of the alpha-hydroxy-acid family. The size and the slow degradation kinetics of PLLA microparticles act as a stimulus for collagen production, providing lasting volume enhancement in lipoatrophy patients.

Prevalence of Complementary and Alternative Medicine Use Among HIV Patients for Perceived Lipodystrophy

BACKGROUND

Complementary and alternative medicine (CAM) use is common among some patients who test positive for human immunodeficiency virus (HIV). Changes in body-fat distribution can occur in some patients on prolonged highly active antiretroviral therapy. Currently, there are fewer effective treatments for the condition. Patients with lipodystrophy may be turning to CAM.

OBJECTIVE

The objective was to investigate the prevalence and perceived benefit of CAM use for perceived body-shape changes among a cohort of HIV-positive patients.

DESIGN/SETTING/SUBJECTS

We surveyed a cross-sectional convenience sample of 74 patients from urban and suburban HIV outpatient clinics in Baltimore, MD, who indicated concerns about body-shape changes. The survey instrument was developed based on validated questionnaires previously used in clinical trials and published work.

RESULTS

CAM use including both supplements and visits to CAM providers was 74% in our study population. In multivariate analysis, users of CAM were more likely to be men (p = 0.016) and to have noticed bodyshape changes after taking HIV medications (p = 0.012). However, very few subjects reported using CAM specifically for lipodystrophy changes. CAM use was more commonly reported for "general health." CAM was primarily more conventional, such as multivitamins or minerals, but several subjects reported using meditation and/or prayer (38%), ginseng (Panax spp.) (3%), St John's wort (Hypericum perforatum) (1%), and acupuncture (1%). More conventional CAM, such as exercise, diet, and vitamins as well as meditation/prayer were perceived to be effective for lipodystrophy as well as for improving the overall sense of well-being.

CONCLUSIONS

The rate of CAM use among the HIV-positive population is high and is primarily used to improve general health.

The Polyalkylimide gel: Experience with Bio-Alcamid™

Bio-Alcamid is a new nonbiodegradable substance which is easy to use and which allows one to create volume on both the body and the face. This substance is extractable even after several years. This allows more patients to use a nonbiodegradable substance for esthetic problems of lipoatrophy treatment or for posttraumatic or therapeutic atrophy of subcutaneous tissue.

Low-dose growth hormone and human immunodeficiency virus-associated lipodystrophy syndrome: a pilot study

BACKGROUND

Treatment with high doses (2-6 mg day(-1)) of human growth hormone (hGH) in patients with human immunodeficiency virus (HIV)-associated lipodystrophy syndrome (HALS) has been shown to increase concentrations of total insulin-like growth-factor-I (IGF-I) more than twofold greater than the normal upper range and is accompanied by adverse effects such as joint pain and glucose intolerance.

MATERIALS AND METHODS

We performed a 16-week open-labelled prospective pilot study in six male HALS patients using a s.c. low-dose hGH, 0.7 mg day(-1), aiming to examine the impact on total and free IGF-I and fat distribution. Glucose metabolism was examined by oral glucose tolerance tests and hyperinsulinaemic euglycaemic clamps.

RESULTS

Total IGF-I increased twofold (P < 0.01) and free IGF-I increased 2.5-fold (P < 0.01) to the level of the normal upper range. HDL-cholesterol increased (P = 0.01). Patients reported improvements of lipodystrophy, which was supported by a decreased waist-to-thigh ratio (P = 0.01), and waist-to-hip ratio (P = 0.06). Ratio of peripheral to trunk soft tissue mass increased (P = 0.01, measured by dual-energy X-ray absorptiometry scans) and a trend towards reduction in percentage of trunk fat was suggested (P = 0.12). Total fat mass, exercise capacity, glucose tolerance, glucose disposal rate and immune status, respectively, did not change (all P > 0.5). The patients did not complain of arthralgia or other known GH-related side-effects.

CONCLUSIONS

Sixteen weeks' treatment of lipodystrophic HIV-infected patients with hGH, 0.7 mg day(-1), increased total and free IGF-I twofold and appeared safe and tolerable. The potential of low-dose hGH in the treatment of HIV-lipodystrophy awaits examination by placebo-controlled, randomized trials.

Use of Ultrasonography-Assisted Liposuction for the Treatment of Human Immunodeficiency Virus--Associated Enlargement of the Dorsocervical Fat Pad

Enlargement of the dorsocervical fat pad (i.e., "buffalo hump") is one manifestation of the lipodystrophy syndrome associated with human immunodeficiency virus. We report our experience with the use of ultrasonography-assisted liposuction in a cohort of 10 patients with this complication.

Effects of Metformin Or Gemfibrozil on the Lipodystrophy of HIV-Infected Patients Receiving Protease Inhibitors

Background

Hypertriglyceridaemia and insulin resistance are common in HIV-infected patients treated with protease inhibitors, particularly in those with lipodystrophy. Whether a therapeutic approach addressed to those metabolic abnormalities may have any impact on body fat is not clear.

Methods

Patients on stable antiretroviral therapy containing protease inhibitors, with abdominal obesity defined by increased waist-to-hip ratio, and plasma triglycerides >200 mg/dl, were randomized to receive blind medication consisting of metformin 850 mg, gemfibrozil 600 mg or placebo every 12 h for 1 year. Weight, height, waist and hip were measured, and fasting blood analyses, including at least CD4 cell count, plasma HIV-1 RNA, lactate, glucose, insulin, triglycerides, total, HDL and LDL cholesterol were performed at baseline and every 3 months. An oral glucose tolerance test, and assessments of total and regional fat by bioimpedance analysis and sonography, respectively, were also done at baseline, 6 and 12 months.

Results

One-hundred-and-eight patients were randomized to placebo ( n=36), gemfibrozil ( n=37) or metformin ( n=35). There was absolute loss of total and regional fat in the three arms without significant changes in the waist-to-hip ratio. However, the loss of fat in patients on gemfibrozil was significantly lower than in patients on placebo. No patient discontinued study drugs due to adverse effects.

Conclusion

In this population of HIV-infected patients, there was a loss of fat along time. The finding of relative preservation of fat associated with gemfibrozil therapy deserves further investigation in the search of potential effective therapies for lipodystrophy in HIV-infected subjects.