HIV-associated lipodystrophy syndrome

Microbial translocation in HIV infection is associated with dyslipidemia, insulin resistance, and risk of myocardial infarction

OBJECTIVE

Microbial translocation has been suggested to be a driver of immune activation and inflammation. It is hypothesized that microbial translocation may be related to dyslipidemia, insulin resistance, and the risk of coronary heart disease in HIV-infected individuals.

DESIGN

Cross-sectional study of 60 HIV-infected patients on combination antiretroviral therapy with viral suppression >2 years and 31 healthy age-matched controls.

METHODS

Lipopolysaccharide (LPS) was analyzed by limulus amebocyte lysate colorimetric assay. Lipids, including cholesterol, low-density lipoprotein (LDL), and triglycerides, were measured. Glucose metabolism was determined using an oral glucose tolerance test. Body composition was determined using whole-body dual-energy x-ray absorptiometry scans and magnetic resonance imaging. The Framingham risk score was used to assess risk of cardiovascular disease and myocardial infarction.

RESULTS

HIV-infected patients had higher level of LPS compared with controls (64 pg/mL vs. 50 pg/mL, P = 0.002). Likewise, HIV-infected patients had higher triglycerides, LDL, and fasting insulin as well as evidence of lower insulin sensitivity compared with controls. Among HIV-infected patients, high LPS was associated with a higher level of triglycerides and LDL and with lower insulin sensitivity. Importantly, among HIV-infected patients, high LPS was associated with a higher Framingham risk score.

CONCLUSIONS

HIV-infected patients with suppressed viral replication had increased level of microbial translocation as measured by LPS. LPS was associated with cardiometabolic risk factors and increased Framingham risk score. Hence, the gastrointestinal mucosal barrier may be a potential therapeutic target to prevent dyslipidemia and future cardiovascular complications in HIV infection.

Lipodystrophy Is Common Among Ethiopian Patients on Highly Active Antiretroviral Therapy but Is Not Associated With Quality of Life or Medication Adherence

Clinical experience suggests that lipodystrophy (LD) can have a profound impact on quality of life (QOL) and medication adherence (MA). Thus, a hospital-based, cross-sectional study was conducted to determine the prevalence of LD and its association with QOL and MA. A total of 405 participants were included in the study. The majority of participants were female (64.5%), with a mean age of 35.69 years (SD = 9.63 years). The prevalence of LD was 30.9%. Multiple logistic regression analysis showed that type of regimen initially used is an independent predictor of severity of LD (adjusted odds ratio, 44.16; 95% confidence interval, 10.56-184.59; P = .001). Quality of life was assessed with the World Health Organization Quality of Life short form instrument (WHOQOL-BREF), and medication adherence was assessed by self-report. The mean WHOQOL-BREF score of the participants was 53.48; the highest mean value was in the domain of physical health (68.56) and the lowest was in the social relationships domain (47.09). The majority of the patients scored lower (ie, in the lowest 5 deciles) in the domains of psychological health, social relationships, and environment compared with physical health. No differences in the WHOQOL-BREF measurements were observed, except in the environment domain, between patients with moderate LD and severe LD ( P = .02). The LD severity was not associated with self-reported MA ( P = .42). With the exception of the psychological health domain ( P = .044), participants' WHOQOL-BREF scores were not significantly associated with MA. Lipodystrophy was not associated with QOL or MA. The prevalence of LD in the present study was within the range of previous reports; however, the mean WHOQOL-BREF score of Ethiopian patients in this study is lower compared with reports from developed countries.

Virus-mediated modulation of the host endocrine signaling systems: clinical implications

Viruses, which are among the simplest infective pathogens, can produce characteristic endocrine manifestations in infected patients. In addition to the classic modification of the host endocrine system by either direct or indirect destruction of the endocrine organs and/or effects exerted by systemic production of inflammatory and/or stress mediators, recent progress in molecular virology and endocrinology has revealed that virus-encoded molecules might alter the host endocrine-signaling systems by affecting extracellular and/or intracellular signal transduction and hormone sensitivity of host target tissues. Here, we provide a brief overview of such viral-mediated modulation of host endocrine signaling systems. We propose that virus-encoded molecules and the signaling systems they influence are potential therapeutic targets for the treatment of disorders that are associated with some viral infections.

Facial lipoatrophy: report of five cases after injection of synthetic filler into naso-labial folds

BACKGROUND

Facial lipoatrophies are rare disfiguring syndromes, most commonly characterized by loss of buccal fat pads.

AIMS

To demonstrate a relationship between facial lipoatrophy and a new synthetic filler device (Profill) used to correct naso-labial folds.

METHODS

Five cases of lipoatrophy, appeared 9 months or later after Profill injections. No systematic abnormalities were found. In one case biopsy reported a destruction of adipocytes with intense fibrosis in the hypodermis.

DISCUSSION

The culpability of this new biodegradable product is highlighted. To our knowledge, this is the first time this adverse reaction has been reported.

CONCLUSION

Serious adverse reactions may appear months after Profill injection, skin testing is not always predictive or sufficient. Clinical studies with long-term follow-up need to be carried out before new filler devices are launched on the market.

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.

Drug interactions between psychoactive substances and antiretroviral therapy in individuals infected with human immunodeficiency and hepatitis viruses

The liver disease characteristic of alcohol dependence encompasses three main related entities: steatosis, alcoholic hepatitis, and cirrhosis. Alcoholic cirrhosis is a leading cause of global morbidity and mortality. Alcohol intake among injecting drug users is a major contributor to transmission of viral infections, such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C viruses (HCV). HIV and HCV coinfected patients develop liver diseases earlier and more severely than the monoinfected individuals, including hepatocellular carcinoma. Interactions exist between the therapeutic drugs used to minimize and control the drug and alcohol dependence. Furthermore, drug-drug interactions occur between the highly active antiretroviral therapy (HAART) and alcohol, different HAART components and methadone, or each one of the therapies with the other, thus contributing to a higher toxicity level. With the evolution of effective antiretroviral therapy, survival of persons with HIV, and the syndrome it causes, acquired immunodeficiency syndrome (AIDS) has increased dramatically. Drug-drug interactions may appear between alcohol and anti-HBV or anti-HCV, therapy in the presence or absence of anti-HIV therapy. Several other medical-, social-, and drug-related factors of this population have to be considered when providing HAART. Because many coinfected patients also have problems with substance use, dealing with their drug dependence is an important first step in an attempt to improve adherence to and tolerance of antiviral therapy. It is necessary to minimize the risk of liver disease acceleration and/or reinfection with hepatitis viruses. Knowledge of potential drug interactions between methadone, antiretroviral therapy, psychoactive drugs, and antipsychotics and the role of coinfection with HBV or HCV and the drugs used in eradicating viral hepatitis permits suitable antiretroviral combinations.

Dyslipidaemia and cardiovascular risk in HIV infection

Cardiovascular disease is increasingly recognised as a consequence of human immunodeficiency virus (HIV) infection in the era of highly active antiretroviral therapy (HAART). Dyslipidaemia is also a feature of HIV infection itself and the antiretroviral drugs from the protease inhibitor classes. Increased rates of atherosclerotic disease and diabetes have been associated with lipodystrophy and now from one of the major causes of morbidity in HIV and acquired immunodeficiency syndrome (AIDS).This review, based on a multi-database keyword search, summarises the lipid changes observed in the course of HIV infection and its treatment, and puts them into the context of other risk factors for cardiac disease, and other causes of cardiovascular disease in HIV.

HIV-1 accessory protein Vpr inhibits the effect of insulin on the Foxo subfamily of forkhead transcription factors by interfering with their binding to 14-3-3 proteins: potential clinical implications regarding the insulin resistance of HIV-1-infected patients

HIV-1 accessory protein Vpr arrests host cells at the G2/M phase of the cell cycle by interacting with members of the protein family 14-3-3, which regulate the activities of "partner" molecules by binding to their phosphorylated serine or threonine residues and changing their intracellular localization and/or stability. Vpr does this by facilitating the association of 14-3-3 to its partner protein Cdc25C, independent of the latter's phosphorylation status. Here we report that the same viral protein interfered with and altered the activity of another 14-3-3 partner molecule, Foxo3a, a subtype of the forkhead transcription factors, by inhibiting its association with 14-3-3. Foxo3a's transcriptional activity is normally suppressed by insulin-induced translocation of this protein from the nucleus into the cytoplasm. Vpr inhibited the ability of insulin or its downstream protein kinase Akt to change the intracellular localization of Foxo3a preferentially to the cytoplasm. This HIV-1 protein also interfered with insulin-induced coprecipitation of 14-3-3 and Foxo3a in vivo and antagonized the negative effect of insulin on Foxo3a-induced transactivation of a FOXO-responsive promoter. Moreover, Vpr antagonized insulin-induced suppression of the mRNA expression of the glucose 6-phosphatase, manganese superoxide dismutase, and sterol carrier protein 2 genes, which are known targets of insulin and FOXO, in HepG2 cells. These findings indicate that Vpr interferes with the suppressive effects of insulin on FOXO-mediated transcription of target genes via 14-3-3. Vpr thus may contribute to the tissue-selective insulin resistance often observed in HIV-1-infected individuals.

Activation of protein phosphatase-2A1 by HIV-1 Vpr Cell death causing peptide in intact CD4+ T cells and in vitro

HIV-1, the etiologic agent of human AIDS, causes cell death in host and non-host cells via HIV-1 Vpr, one of its auxiliary gene product. HIV-1 Vpr can also cause cell cycle arrest in several cell types. The cellular processes that link HIV-1 Vpr to the cell death machinery are not well characterized. Here, we show that the C terminal portion of HIV-1 Vpr which encompasses amino acid residues 71-96 (HIV-1 Vpr(71-96)), also termed HIV-1 Vpr cell death causing peptide, is an activator of protein phosphatase-2A(1) when applied extracellularly to CD(4+) T cells. HIV-1 Vpr(71-96) is a direct activator of protein phosphatase-2A(1) that has been purified from CD(4+) T cells. Full length HIV-1 Vpr by itself does not cause the activation of protein phosphatase-2A(1) in vitro. HIV-1 Vpr(71-96) also causes the activation of protein phosphatase-2A(0) and protein phosphatase-2A(1) from brain, liver, and adipose tissues. These results indicate that HIV-1 can cause cell death of infected cells and non-infected host and non-host cells via HIV-1 Vpr derived C terminal peptide(s) which act(s) by cell penetration and targeting of a key controller of the cell death machinery, namely, protein phosphatase-2A(1). The activation of other members of the protein phosphatase-2A subfamily of enzymes which are involved in the control of several metabolic pathways in brain, liver, and adipose tissues by HIV-1 Vpr derived C terminal peptide(s) may underlie various metabolic disturbances that are associated with HIV-1 infection.

Human immunodeficiency virus type-1 accessory protein Vpr: a causative agent of the AIDS-related insulin resistance/lipodystrophy syndrome?

Recent advances in the development of three different types of antiviral drugs, the nucleotide and non-nucleotide analogues acting as reverse transcriptase inhibitors (NRTIs) and the nonpeptidic viral protease inhibitors (PI), and their introduction in the management of patients with AIDS, either alone or in combination, have dramatically improved the clinical course of the disease and prolonged life expectancy in patients with AIDS. The increase in life expectancy in association with the long-term use of the above antiviral agents, however, have generated novel morbidities and complications. Central among them is the quite common AIDS-related insulin resistance and lipodystrophy syndrome, which is characterized by a striking phenotype and marked metabolic disturbances. To look for the pathologic causes of this particular syndrome, we focused on one of the HIV-1 accessory proteins, Vpr, which has multiple functions, such as virion incorporation, nuclear translocation of the HIV-1 preintegration complex, nucleo-cytoplasmic shuttling, transcriptional activation, and induction of apoptosis. Vpr may also act like a hormone, which is secreted into the extracellular space and affects the function of distant organs. Vpr functions as a coactivator of the glucocorticoid receptor and potentiates the action of glucocorticoid hormones, thereby inducing tissue glucocorticoid hypersensitivity. Vpr also arrests host cells at the G2/M phase of the cell cycle by interacting with novel 14-3-3 proteins. Vpr facilitates the interaction of 14-3-3 and its partner protein Cdc25C, which is critical for the transition of G2/M checkpoint in the cell cycle, and suppresses its activity by segregating it into the cytoplasm. The same Vpr protein also suppresses the association of 14-3-3 with other partner molecules, the Foxo transcription factors. Since the Foxo proteins function as negative transcription factors for insulin, Vpr may cause resistance of tissues to insulin. Through these two newly identified functions of Vpr, namely, coactivation of glucocorticoid receptor activity and inhibition of insulin effects on Foxo proteins, Vpr may participate in the development of AIDS-related insulin resistance/lipodystrophy syndrome.

A case of HIV-associated facial lipoatrophy treated with 1000-cs liquid injectable silicone

BACKGROUND

Patients infected with the HIV may experience HIV-associated lipodystrophy, a symptom of which is facial lipoatrophy, a dramatic loss of subcutaneous facial tissue. This visible manifestation of HIV infection causes significant psychosocial pain for patients and has been associated with impaired compliance with medical regimens.

OBJECTIVE

To improve the appearance of facial lipoatrophy in a safe, long-lasting, expeditious, and relatively economical manner.

METHODS

An HIV-associated lipodystrophy patient with facial lipoatrophy underwent multiple sessions of soft-tissue augmentation therapy with liquid injectable silicone (LIS) using the microdroplet serial puncture technique.

RESULTS

Administration of LIS by the microdroplet serial puncture technique produced satisfactory improvement of areas of facial atrophy. The treatment time is limited, the patient discomfort and morbidity are minimal, and results are long lasting. Patients report significant satisfaction with treatment.

CONCLUSION

LIS administered by the microdroplet serial puncture technique is a safe and effective method for treating HIV-associated facial lipoatrophy and compares favorably with other methods of tissue augmentation.

A transgenic mouse with a deletion in the collagenous domain of adiponectin displays elevated circulating adiponectin and improved insulin sensitivity

Adiponectin is a plasma protein expressed exclusively in adipose tissue. Adiponectin levels are linked to insulin sensitivity, but a direct effect of chronically elevated adiponectin on improved insulin sensitivity has not yet been demonstrated. We identified a dominant mutation in the collagenous domain of adiponectin that elevated circulating adiponectin values in mice by 3-fold. Adiponectinemia raised lipid clearance and lipoprotein lipase activity, and suppressed insulin-mediated endogenous glucose production. The induction of adiponectin during puberty and the sexual dimorphism in adult adiponectin values were preserved in these transgenic animals. As a result of elevated adiponectin, serum PRL values and brown adipose mass both increased. The effects on carbohydrate and lipid metabolism were associated with elevated phosphorylation of 5'-AMP-activated protein kinase in liver and elevated expression of peroxisomal proliferator-activated receptor gamma2, caveolin-1, and mitochondrial markers in white adipose tissue. These studies strongly suggest that increasing endogenous adiponectin levels has direct effects on insulin sensitivity and may induce similar physiological responses as prolonged treatment with peroxisomal proliferator-activated receptor gamma agonists.

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.

Drug-induced rhabdomyolysis after concomitant use of clarithromycin, atorvastatin, and lopinavir/ritonavir in a patient with HIV

A case report of drug-induced rhabdomyolysis in a 34-year-old HIV-infected male with a history of liver disease and concomitant use of clarithromycin, atorvastatin, and lopinavir/ritonavir is presented.

A qualitative study of the psychosocial implications of lipodystrophy syndrome on HIV positive individuals

OBJECTIVES

To investigate the psychosocial impact of lipodystrophy on the lifestyles of HIV positive patients on highly active antiretroviral therapy (HAART).

METHODS

In-depth interviews were conducted with 14 HIV positive patients on HAART at an outpatient sexually transmitted infections (STI) and HIV clinic in central London. Qualitative data from interview transcripts were analysed using grounded theory to elicit key categories and subcategories.

RESULTS

Three main themes relating to lipodystrophy emerged: effect on the individual; impact on the social world of the individual; responses of the individual. Lipodystrophy had physical and psychological effects, ranging from bodily discomfort to low self esteem and depression. Owing to its physical manifestations it was viewed as a visible marker of HIV disease. At the level of social functioning, lipodystrophy led to problems with personal and family relationships, although having a partner was protective. Individuals reported narrowing their social world, in some cases to degrees of social isolation. Individual responses included changes in diet, increased exercise regimes, steroid use and plastic surgery (mainly collagen injections to the face). For those who had experienced serious illness related to HIV, there was a more sanguine acceptance of lipodystrophy as an unfortunate consequence of longevity and drug therapy

CONCLUSIONS

Health professionals need to address the psychosocial implications of lipodystrophy, including the ways in which it may affect different groups and their adherence to therapy. Formative evaluations are needed to assess the potential for targeted interventions.

Lipodystrophy, insulin resistance, diabetes mellitus, dyslipidemia, and cardiovascular disease in human immunodeficiency virus infection

The introduction of highly active antiretroviral therapy has significantly reduced morbidity and mortality in patients infected with the human immunodeficiency virus. Treatment with antiretroviral agents--protease inhibitors in particular--has uncovered a syndrome of abnormal fat redistribution, dyslipidemia, and impaired glucose metabolism, collectively termed lipodystrophy syndrome. The cause of the syndrome seems to be multifactorial; however, its exact mechanisms have yet to be elucidated. Accelerated risk for cardiovascular disease is likely to be a major concern in these patients in the future. At this time, no clinical guidelines are available for the prevention and/or the treatment of lipodystrophy syndrome. The available treatment options range from switching the different antiretroviral drugs and lifestyle modifications to the use of pharmacologic agents to treat patients with dyslipidemia, impaired glucose tolerance and/or diabetes, and changes in body composition. This review emphasizes the clinical features, potential molecular mechanisms, and treatment options for patients infected with human immunodeficiency virus who have lipodystrophy syndrome.

Facial lipoatrophy secondary to a new synthetic filler device (Profill) treated by lipofilling

BACKGROUND

Facial lipoatrophies are rare, disfiguring syndromes requiring correction. Lipofilling is an 'ecological' treatment that does not carry any risk of allergy.

AIM

To demonstrate efficacy of this technique in facial lipoatrophy.

RESULTS

This technique was used in four patients suffering from lipoatrophy secondary to the injection of a new filler device (Profill). The technique and results are described. After three procedures, there was more than 70% improvement (with a mean follow-up period of one year).

CONCLUSION

These particular lipoatrophies are improved by lipofilling. This technique is particularly relevant in treating patients who have shown signs of trauma following filling procedures using allogenic materials.

Hyperlipidemia in HIV-positive patients receiving antiretrovirals

OBJECTIVE

To assess the frequency of lipid abnormalities and treatment outcomes for hyperlipidemia in HIV-positive patients receiving antiretroviral (ARV) therapy as outpatients at a Veterans Affairs HIV clinic.

METHODS

All patients monitored for at least 3 months were reviewed. Data collected included age, most recent CD4+ cell count and viral load, ARV history, and all fasting cholesterol, triglyceride, high-density lipoprotein (HDL), and low-density lipoprotein (LDL) values. The ARV therapy at the time of lipid readings was classified as including protease inhibitors (PI+) or not including them (PI-). Lipid values were compared with goals per national guidelines and risk factors.

RESULTS

Male patients (n = 101) providing 210 lipid profiles were evaluated (median 2 per patient). Median age was 51 years. Fourteen patients were diabetic, 31 were hypertensive, and 6 patients had documented coronary disease. Mean cholesterol, triglycerides, and LDL values were significantly higher in PI+ (n = 50) compared with those of PI- patients (n = 51; p < 0.05). HDL values were not different between groups. Significantly more PI+ patients had lipid concentrations above recommended goals compared with PI- patients (17 vs. 7; p = 0.04). Six patients achieved lipid goals after following a low-fat diet (4 PI+). Fifteen subjects (11 PI+) were being treated with medications. Ten patients (67%) reached lipid goals, 2 had not reached goals (13%), and 3 (20%) were undergoing medication titration.

CONCLUSIONS

Our HIV-infected patients had significantly higher cholesterol, triglyceride, and LDL values when PI+. In contrast to other reports, the majority of patients treated for lipid abnormalities achieved treatment goals.

Efficacy of highly active antiretroviral therapy in HIV-1 infected children

Although the reduction in HIV-1-related deaths with highly active antiretroviral therapy (HAART) is similar in adults and children, the extent of the changes in two important surrogate markers HIV-1 RNA levels and CD4+ T cell counts, differs widely. In most paediatric studies virological response rates to HAART are inferior to those in adults. This review provides an overview of the paediatric clinical studies using HAART and seeks to improve the understanding of factors that may contribute to success or failure of HAART in children. An overview of all current articles on paediatric clinical trials using HAART is provided. 23 papers were available. HIV-1 RNA loads and CD4+ T cell counts were used as primary outcome measures. Virological response rates were highly variable, both among the different antiretroviral drugs but also among different studies using the same medication. Four studies in which dosages of the administrated protease inhibitor (PI) were adjusted after pharmacokinetic evaluation had superior virological response rates compared with those in which fixed dosages were used. Immunological response rates were more uniform than virological responses. In almost all studies increases of CD4+ T cell counts are reported independent of the extent of the virological response. Side-effects of HAART were generally mild, transient, and of gastrointestinal origin. Significant percentages of patients with serum lipid abnormalities were reported in three paediatric studies. However, signs of clinical lipodystrophy were not observed. The inferior virological response rates, which have been reported in HIV-1 infected children treated with HAART form a reflection of the challenges that are encountered in the treatment of these children. Difficulties with adherence and with the pharmacokinetics of PIs in children require an intensive, child-adjusted approach. A practical approach to therapy in institutions without tertiary care facilities may be induction therapy with a lopinavir containing regimen (lacking a need for therapeutic drug monitoring), to reduce high viral load levels followed by an easily tolerated maintenance regimen, for example containing abacavir or nevirapine.

Long-term exposure to lifelong therapies

Three categories of highly active antiretroviral therapy (HAART)-associated major toxic effects have been identified: nucleoside-related toxic effects (e.g., neuropathy, myopathy, pancreatitis, hepatic steatosis, lactic acidosis, and possibly lipoatrophy), metabolic complications (e.g., fat redistribution, insulin resistance, and hyperlipidemia), and bone disease (e.g., osteopenia and/or osteoporosis). The toxic effects caused by nucleosides are hypothesized to be a result of mitochondrial injury and include myopathy, pancreatitis, liver failure, and lactic acidosis. Alterations in lactic acid metabolism range from common instances of asymptomatic lactic acidemia to rare occurrences of life-threatening lactic acidosis with hepatic steatosis. A metabolic syndrome consisting of lipodystrophy (i.e., fat redistribution), hyperlipidemia and insulin resistance has been observed, particularly with protease inhibitor treatment. Some additive interaction between protease inhibitors and nucleosides has also been described. The potential relationship of these metabolic abnormalities to increased risk of cardiovascular disease and diabetes has broad implications on long-term patient management. Lipodystrophy associated with HAART is generally accompanied by potentially serious abnormalities, including dyslipidemia (i.e., hypercholesterolemia and hypertriglyceridemia) and altered glucose metabolism (i.e., insulin resistance). Regimens of HAART may have adverse effects on bone metabolism, as indicated by emerging reports of osteopenia, osteoporosis, and avascular necrosis.

Mitochondrial involvement in antiretroviral therapy-related lipodystrophy

OBJECTIVES

The management of HIV infection has greatly improved during recent years essentially because of the appearance of new antiretroviral drugs. Highly active antiretroviral therapy (HAART) has achieved important reductions of viraemia and significant recoveries of CD4(+) cell counts in HIV-infected patients. Nonetheless, cases of HIV-infected individuals experiencing lipodystrophy (LD) are being increasingly reported. The purpose of this work was to analyse whether the presence of mitochondrial abnormalities is a frequent feature in LD, since we previously detected mitochondrial abnormalities in an HIV-patient. The second main objective was to study whether LD could be associated with a specific drug.

DESIGN

Seven HIV patients presenting LD and five HIV non-LD controls participated in the study. LD patients met the following criteria: (1) LD was their only clinical abnormality, (2) LD was clinically relevant, (3) compliance with antiretroviral treatment was higher than 90% and (4) patients did not have personal or familial history suggestive of mitochondrial disease or neuromuscular disorder.

METHODS

Histological stainings, histo-enzymatic reactions, enzymatic and respiratory activities of mitochondrial respiratory chain complexes, and mitochondrial DNA (mtDNA) depletion and rearrangements were examined on muscle mitochondria.

RESULTS

Structural muscle abnormalities, mitochondrial respiratory chain dysfunction or mtDNA deletions were detected in all HIV lipodystrophic patients.

CONCLUSIONS

The mitochondrial abnormalities found suggest that mitochondrial dysfunction could play a role in the development of antiretroviral therapy-related lipodystrophy.

Lipodystrophy syndrome in children infected with human immunodeficiency virus

Lipodystrophy syndrome (LDS), a fat-wasting condition commonly reported in adults infected with human immunodeficiency virus (HIV), has been linked to the use of antiretroviral agents. Recently, LDS was observed in children infected with HIV Little is known about the pathophysiology of this condition, although it is believed that LDS has many causes and modes of presentation. Even less is known about what long-term effects LDS will have on HIV-infected patients. Three patients who developed LDS were observed in a pediatric HIV clinic. Due to the lack of knowledge about the condition's natural course and the benefits versus risks of treatment, they were not treated specifically for LDS. Their lipid profiles, however, continue to be monitored closely twice/year.

HIV lipodystrophy: review of the syndrome and report of a case treated with liposuction

BACKGROUND

A syndrome characterized by loss of fat on the face and limbs, localized fatty deposits on the trunk, and metabolic disturbances is becoming increasingly recognized in the human immunodeficiency virus (HIV) patient population.

OBJECTIVE

To increase awareness of this syndrome among dermatologists and dermatologic surgeons and to review its various treatment options, including liposuction.

METHODS

We present a patient with HIV lipodystrophy syndrome who underwent tumescent liposuction. We also describe our experience with liposuction in the management of this condition and review the treatment options that have been proposed in the literature.

RESULTS

In the medical management of HIV lipodystrophy, various agents have been utilized but most have yielded disappointing results. Preliminary evidence on the use of tumescent liposuction in these patients suggests that significant improvement in the cosmetic disfigurement can be achieved.

CONCLUSION

This syndrome is common among HIV-infected patients and remains difficult to treat. Although medical therapy may be preferable in most patients, liposuction represents a viable option in selected individuals.

Evidence of hypertriglyceridemia in managing HIV patients on efavirenz

Of the recently approved antiretroviral agents, efavirenz has become a popular medication for the treatment of HIV infection. The efficacy of an efavirenz-based regimen has allowed the use of a combination of this medication with other antiretroviral agents in all levels of HIV disease, resulting in decreased viral replication and positive clinical results. Efavirenz is also proposed as an acceptable agent to switch to from a protease inhibitor-based regimen to reduce the risk of metabolic complications. In addition, the favorable side-effect profile, diminished pill burden for clients, and daily dosing have contributed to its popularity. Primary care practitioners should be cognizant of the possible side-effect profile of antiretroviral therapy combinations and enter into a collaborative relationship with the infectious disease clinician to ensure safe and effective patient care.

Three-drug combinations of emivirine and nucleoside reverse transcriptase inhibitors in vitro: long-term culture of HIV-1-infected cells and breakthrough viruses

Emivirine (EMV) is a non-nucleoside reverse transcriptase inhibitor currently undergoing Phase III clinical trials in HIV-1-infected patients. In this study, the anti-HIV-1 activity of EMV in combination with two nucleoside reverse transcriptase inhibitors was examined in cell cultures. The combinations EMV plus stavudine (d4T) plus lamivudine (3TC) and EMV plus d4T plus didanosine (ddI) synergistically inhibited HIV-1 replication in MT-4 cells. Although not statistically significant, EMV plus d4T plus 3TC appeared to be more synergistic than EMV plus d4T plus ddI. Synergism was also observed with any two-drug combinations, such as EMV plus d4T, EMV plus 3TC, EMV plus ddI, d4T plus 3TC, or d4T plus ddI. The three-drug combinations completely suppressed HIV-1 replication for at least 40 days after virus infection. Except for d4T, virus emerged in the presence of every compound alone or some combinations at lower concentrations. Susceptibility tests of the breakthrough viruses to each compound showed that the viruses obtained in the presence of EMV alone and 3TC alone were significantly less susceptible to EMV and 3TC, respectively. These viruses had specific amino acid mutations in their reverse transcriptase.

Smaller amounts of antiretroviral drugs are needed when combined with an active ribozyme against HIV-1

We have tested for combined anti-HIV-1 effects of a hammerhead ribozyme and antiretroviral drugs and the possibility of reducing the drug burden of patients on highly active antiretroviral therapy (HAART). The antiretroviral compounds used represent the three groups in HAART: nucleoside analogue reverse-transcriptase inhibitors, nonnucleoside reverse-transcriptase inhibitors, and protease inhibitors. A human T cell line (HUT78), stably expressing a hammerhead ribozyme targeted to nef (hhRz.nef(9016-9029)), was infected with HIV-1(SF2) in the presence of a single drug. The combined effects on HIV-1 replication were measured by p24 antigen determinations over a 2-week period. In the presence of the ribozyme, smaller amounts of antiretroviral drugs were required to reduce the HIV-1 p24 levels equally as much as when only drugs were present. The results support a strategy of combining ribozyme gene therapy with HAART to improve the long-term outcome of anti-HIV-1 therapy.

Glucose disorders associated with HIV and its drug therapy

OBJECTIVE

To review the impact that factors such as HIV infection, antiretrovirals, and other commonly used drug therapies have on glucose metabolism in HIV-infected patients.

DATA SOURCES

Pertinent literature was identified via a MEDLINE search from 1980 to April 2000 and through secondary sources (abstracts presented at recent scientific meetings, manufacturers' package inserts). The key words used were antiretroviral therapy, HIV infection, insulin resistance, and metabolic abnormalities. All information deemed relevant to evaluate the impact that HIV infection and drug therapy have on glucose metabolism in HIV-infected patients was included.

DATA SYNTHESIS

The viral burden and stress that are present in HIV-infected patients elicit a complex hormonal and immunologic response that may alter various biochemical pathways, including glucose metabolism. Although rare before the era of potent antiretroviral therapy, insulin resistance has now been described as an important component of the lipodystrophy syndrome. The complex and multifactorial nature of glucose metabolism dysregulation makes management of hyperglycemia or diabetes mellitus challenging in HIV-infected patients. In such a context, a set of recommendations was developed to guide practitioners in assessing, treating, and monitoring hyperglycemia or diabetes mellitus in HIV-infected patients.

CONCLUSIONS

Alterations of glucose metabolism observed in HIV-infected patients are more frequent since the introduction of potent antiretroviral therapy. Although the etiology of such abnormalities remains unknown, protease inhibitors and, to a lesser extent, nucleoside reverse transcriptase inhibitors are believed to participate in their pathogenic mechanisms. Because of similarities to the pathogenesis of diabetes mellitus, management of antiretroviral-induced hyperglycemia could follow that the recommendations of the American Diabetes Association, with special considerations for monitoring patients with HIV infection. Future studies of altered glucose metabolism in HIV-infected patients should focus on understanding the precise mechanism or causes of this complication so that preventive and therapeutic guidelines can be further evaluated.

HIV protease inhibitors stimulate hepatic triglyceride synthesis

Hyperlipidemia may complicate the use of HIV protease inhibitors (PIs) in AIDS therapy. To determine the cause of hyperlipidemia, the effect of PIs on lipid metabolism was examined with HepG2 liver cells and AKR/J mice. In HepG2 cells, the PIs ABT-378, nelfinavir, ritonavir, and saquinavir stimulated triglyceride synthesis; ritonavir increased cholesterol synthesis; and amprenavir and indinavir had no effect. Moreover, nelfinavir increased mRNA expression of diacylglycerol acyltransferase and fatty acid synthase. The retinoid X receptor agonist LG100268, but not the antagonist LG100754, further increased PI-stimulated triglyceride synthesis and mRNA expression of fatty acid synthase in vitro. In fed mice, nelfinavir or ritonavir did not affect serum glucose and cholesterol, whereas triglyceride and fatty acids increased 57% to 108%. In fasted mice, ritonavir increased serum glucose by 29%, cholesterol by 40%, and triglyceride by 99%, whereas nelfinavir had no effect, suggesting these PIs have different effects on metabolism. Consistent with the in vitro results, nelfinavir and ritonavir increased triglyceride 2- to 3-fold in fasted mice injected with Triton WR-1339, an inhibitor of triglyceride clearance. We propose that PI-associated hyperlipidemia is due to increased hepatic triglyceride synthesis and suggest that retinoids or meal restriction influences the effects of select PIs on lipid metabolism.