Access to treatment for facial fat wasting in UK

A recent meeting organised by the Royal Free Centre for HIV Medicine and HIV i-Base reviewed the current state of access to treatments for facial fat loss (lipoatrophy) in the UK, and offered new insights into the process of facial fat loss - and what can be done to arrest it.

The process of facial fat loss

Facial fat loss tends to occur quite rapidly, often within three months. The Chelsea and Westminster Hospital in London is currently evaluating whether it is better to treat facial fat loss as soon as it becomes pronounced, or whether to wait a further three months to determine whether the restorative effect of New Fill is more pronounced in patients whose facial fat loss appears to have progressed further.

Facial fat loss occurs mainly in compartment of facial fat called the buccal fat pad, which lies in the area below the eyes and cheekbone, and to either side of the nose. The buccal fat pad is one of the areas that begins to shrink with age. This fat pad plays an important role in structuring the rest of the facial features, as New York plastic surgeon Jeff Brande showed at the meeting. Transfers of fat into this area have the effect of partially correcting some of the other distortions that begin to appear once this fat pad begins to shrink.

The buccal fat pad is the main deposit of brown fat in the face. This is yet another peculiarity of the lipodystrophy syndrome; in other parts of the body, brown fat deposits grow, so why should the facial depot diminish?

Also, facial fat loss is not always accompanied by subcutaneous fat loss from the limbs, at least in the perception of people affected. At present it is unclear whether this is because facial fat loss is more noticeable, even in people with a relatively thick layer of subcutaneous layer of fat on their limbs, or whether a proportion of people will only experience noticeable fat loss in the face.

However the buccal fat pad is not the only part of the face that is affected. Fat deposits on the sides of the temples also shrink, and in some people the parotid gland (below the ear at the corner of the jaw) can become swollen, further changing the shape of the face.

Two treatments were discussed at the meeting, polylactic acid and autologous fat injections (where a person’s subcutaneous fat is harvested and then injected into the face). See Treatment for body fat and metabolic changes on this site for further information on studies of polylactic acid, together with the December 2001 edition of AIDS Treatment Update for information on treatment with polylactic acid, and autologous fat transfer.

Current access to treatment for facial lipoatrophy

As the table below shows, access to treatments that can repair facial fat loss is extremely limited – currently, less than 100 patients are receiving New Fill treatment through clinical trials or other means in the UK. However, demand for private treatment is such that New Fill’s distributor is employing a nurse two days a week to carry out treatment for people with facial fat loss who have decided to go private – at a cost of around £400 a session.

The current cost of the product to the NHS is £150 per session, excluding the cost of staff time to carry out the injection. One London hospital has decided to begin providing treatment on the basis that patients will cover the cost of New Fill, while the clinic will cover the cost of providing the injections.

Is there any possibility that New Fill treatment will become more widely available soon? Dr Mike Youle pointed out that new treatments tend to be introduced centre by centre in the UK and the take up of new procedures or therapies is very much driven by the interest of clinicians in trying the new procedure or drug. At the Royal Free Hospital, Dr Youle has been unable to persuade plastic surgeons to become involved with providing the treatment, and does not have time within a very busy clinic schedule to carry out the injections himself, so his centre is unable to offer the treatment.

In London the availability of new treatments is determined partially by how much money is available to pay for the treatment, and also by the attitudes of individual Drugs and Therapeutics Committees towards particular therapies. At the Royal Free Hospital the Drugs and Therapeutics Committee has signaled that it does not consider New Fill treatment a priority.

HIV commissioners in London do not make case by case decisions about whether to pay for new drugs during the course of the fincial year, points out Jonathan O’Sullivan of East London and City Health Authority, but only the general level of support for particular centres based on what the clinics bid for. If clinics don’t factor in the cost of new treatments to their calculations at the beginning of the financial year, they have to wait until the following April for their funding to reflect new cost pressures, and in the meantime negotiate within the individual Trust for further support via the Drugs and Therapeutics committees, for example. This mechanism makes it difficult to lobby centrally for increased funding, unlike in France, where treatment advocates are negotiating with the Ministry of Health for funding to cover New Fill treatment.

The London HIV Consortium (the group of commissioners who commission HIV services in the capital) is currently engaged in a horizon scanning exercise to identify new cost pressures such as drugs and tests that could become standard of care. This exercise is designed to manage the entry of new drugs and to ensure that cost pressures don’t lead to post code prescribing in London, but it could also lead to pressure on consultants to prescribe cheaper drugs where evidence of comparable efficacy exists, in the view of some consultants. There was widespread support at the meeting for a revision to the British HIV Association guidelines to cover treatment for facial fat loss.