Four year treatment break does not reverse fat loss, says case report

A break from antiretroviral treatment lasting four years did not reverse fat loss caused by anti-HIV drugs in an HIV-positive woman, investigators report in the October 3^rd edition of BMC Infectious Diseases. However, during this time the fat accumulation which the women had also experienced whilst taking anti-HIV therapy was almost completely reversed.

“Loss of peripheral adipose tissue caused by highly active antiretroviral therapy may not be fully reversible after treatment interruption, even in the long run”, write the Italian investigators. They also stress the potentially very serious consequences of body fat changes caused by antiretroviral therapy, noting that their patient “at the time of therapy interruption…declared she would prefer dying than living with such disfiguring changes in her body shape.”

Lipodystrophy is now a well recognised side-effect of antiretroviral therapy, and between 5 – 20% of patients taking anti-HIV treatment are thought to experience a severe form of the side-effect, with older patients, women and individuals with more advanced HIV disease seemingly at greater risk.

Several strategies have been explored as a way of treating lipodystrophy. These include switching anti-HIV drugs, and the use of drugs such as rosiglitazone and metformin to directly treat body fat changes. Since it is unclear whether a prolonged treatment break can help reverse body fat changes, investigators reported the case of a 35 year-old woman with severe fat accumulation and fat loss caused by HIV therapy, who took a four year break from anti-HIV drugs.

The woman was diagnosed with HIV in 1989, and in July 1997, when her CD4 cell count was below 100 cells/mm³ she started potent anti-HIV therapy with a regimen comprising d4T, 3TC and indinavir. After twelve weeks the woman’s viral load had fallen to 400 copies/ml and her CD4 cell count had increased to over 200 cells/mm³. However, in April 1998, after nine months of treatment, she complained of fat accumulation on the breasts, waist and over the lumber spine. Rapidly progressing fat loss followed soon after. The woman continued to take her anti-HIV therapy until 2000, by which time her CD4 cell count was over 500 cells/mm³. At this time she was offered the opportunity to switch to a simplified anti-HIV treatment regimen, which she declined, preferring a complete break from treatment.

This lasted for four years, at the end of which the woman’s CD4 cell count had fallen to 84 cells/mm³ and her viral load was approximately 25,000 copies/ml. During the break from treatment the fat accumulation on the lumbar spine disappeared, the fat pads on the waist greatly reduced and the enlargement of the woman’s breasts was reduced. However, there was little improvement in the fat loss the woman had experienced, with only marginal improvement in the upper extremities and no improvement at all to the fat loss from the buttocks.

“Our observation provides…evidence that severe combined lipodystrophy in our patient was only partially reversible, even under the ideal conditions of a long lasting and safe treatment interruption”, observe the investigators. They conclude that as newer anti-HIV drugs do not seem to have body fat changes as a side-effect, “the prevention of lipodystrophy should become a key issue when tailoring individual regimens”.