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One-third of Rwandan ART patients show lipodystrophy, more common in city dwellers
Tom Egwang, Tuesday, December 04, 2007
HIV-positive Rwandese patients on a World Health Organization (WHO)-recommended antiretroviral therapy regimens had a high prevalence of body fat redistribution (lipodystrophy), according to a report published in the December 1st edition of the Journal of Acquired Immune Deficiency Syndromes.

According to the study, HIV-positive patients with lipodystrophy had increased waist-to-hip ratio (WHR) and elevated cholesterol and glucose levels which put them at an increased risk of cardiovascular disease and type-2 diabetes, respectively.

International and national efforts are underway to increase universal antiretroviral access to millions of HIV-positive patients across sub-Saharan Africa. While anti-HIV treatment has undoubtedly decreased HIV-related morbidity and deaths, it is associated with lipodystrophy.

Lipodystrophy exerts a profound socio-psychological impact on the patient and the community. The disfiguration results in not only stigmatisation and marginalisation of patients but also reduced adherence to antiretroviral treatment. The latter is a risk factor for drug resistance.

The prevalence of lipodystrophy in African patients on anti-HIV treatment has been reported only to a limited extent thus far. In this study, a team of Rwandese and South African researchers investigated the prevalence of lipodystrophy and its metabolic effects in a large cohort of Rwandese patients on antiretroviral drugs.

The study took place at the Centre Hospitalier Universitaire de Kigali, Treatment and Research AIDS Centre, Hospitalier Universitaire de Butare, and five HIV/AIDS clinics. The cohort consisted of 571 individuals with confirmed HIV infection who were on WHO-recommended antiretroviral therapy for six months or more without opportunistic infections, and were between 21 and 50 years of age.

The prevalence of lipodystrophy was assessed by a self-reporting questionnaire, clinical confirmation by a physician, and measurement of waist and hip circumference. Metabolic variables were measured in 100 HIV-positive adults with lipodystrophy, 50 HIV-positive adults without lipodystrophy, and 50 HIV-negative controls. Pregnant and breastfeeding women were excluded.

Fasting blood samples were obtained to establish the prevalence of impaired fasting glucose (IFG; glucose more than 5.6 mmol/l9), hypertriglyceridemia (triglycerides more than 1.7 mmol/10), and hypercholesterolemia (total cholesterol more than 5.0 mmol/l10) in the three groups.

An antiretroviral regimen of d4T (stavudine, Zerit), 3TC (lamivudine, Epivir), and nevirapine was used by 81.6% of patients; none received protease inhibitors. Lipodystrophy was less common in patients taking efavirenz by comparison with those not taking this drug (15.4 % of 39 individuals versus 35.3 % of 532 individuals; P = 0.01).

Lipodystrophy was observed in 34% (48.5% in urban groups and 17.3% in rural groups) of patients. Interestingly, the prevalence of lipodystrophy was higher in urban than rural patients. This was confirmed by a statistical model which showed that rural residence was protective against this condition.

The prevalence of lipodystrophy in patients receiving anti-HIV treatment for more than 72 weeks was 69.6%. The duration of antiretroviral therapy was significantly longer in HIV-positive patients with lipodystrophy than in HIV-positive individuals who did not have the side-effect (P < 0.001). This was also confirmed by a statistical model which showed that being on antiretroviral therapy for a longer period increased the risk of lipodystrophy.

Peripheral lipoatrophy (reduced fat deposition) combined with abdominal lipohypertrophy (increased fat deposition) was observed in 72% of patients with lipodystrophy subjects. The body regions which were more frequently affected were the abdomen (84 %), legs (70 %), face (67 %), arms (66 %), breasts (47 %), buttocks (46 %), and neck (34 %). The body fat re-distribution was similar in rural and urban patients and in both sexes.

HIV-positive adults with lipodystrophy had a significantly higher waist-to-hip ratio (WHR; 0.99 ± 0.05 vs. 0.84 ± 0.03: P < 0.0005) than HIV-positive adults without lipodystrophy. Median (and interquartile range) cholesterol concentrations were significantly higher in the HIV-positive adults with lipodystrophy than in HIV-positive adults who did not have the side-effect (3.60 [1.38] mmol/l) versus 3.19 [0.65] mmol/); P < 0.005) and control (3.60 [1.38] mmol/l versus 3.13 [0.70] mmol/l; P < 0.0005) groups.
The prevalence of hypertriglyceridemia was significantly higher in the patients with lipodystrophy than in the two other groups (P = 0.03). Impaired fasting glucose was observed in 18% of HIV-positive adults with lipodystrophy, 16% of HIV-positive adults with lipodystrophy, and 2% of controls, but insulin levels did not differ. There was no correlation between the duration of antiretroviral therapy and levels of triglyceride, cholesterol, glucose, or insulin sensitivity.

In conclusion, African subjects with lipodystrophy had increased WHR, glucose, and cholesterol levels. Antiretroviral therapy in the long-term may predispose to a higher risk of cardiovascular disease, say the authors.

Reference

Mutimura E et al. Metabolic function and the prevalence of lipodystrophy in a population of HIV-infected African subjects receiving highly active antiretroviral therapy. J Acquir Immune Defic Syndr 46: 451–455, 2007.