Fat loss (lipoatrophy)

Lipoatrophy symptoms
Role of d4Tand AZT
Other nukes?
Switching treatment
New-Fill
Bio-Alcamid
Autologous fat transfer (Coleman technique)
Other injectable substances

More about lipodystrophy:

Associated drugs: d4T (Stavudine), AZT (zidovudine, Retrovir), possibly efavirenz (Sustiva).

Lipoatrophy symptoms

Lipoatrophy is the medical term for fat loss, and it is currently seen as the main symptom behind the lipodystrophy syndrome.

Symptoms include loss of fat from under the skin on your arms and legs, which can make your veins look more prominent. It also includes loss from the face - generally resulting in sunken cheeks and temples.

Fat can be lost from the soles of the feet making walking more tiring.

Role of d4T and AZT

Clinical ipoatrophy - where you can see a change in body fat - is common after long-term treatment that includes either d4T or AZT. Both these drugs affect the way that fat cells are produced at a cellular level, sometimes after only a few weeks or months of treatment.

Nucleosides have been shown to damage the energy producing part of healthy cells called mitochondria.

In most studies, d4T damages fat cells at around twice the rate of AZT. d4T may also lead to lipoatrophy that is more difficult to reverse than that caused by AZT. This is because it may damage cells at an earlier stage.

Other nukes?

Not all nukes cause lipoatrophy. 3TC, FTC, tenofovir and abacavir do not seem involved. The role of ddI is unclear.

The risk of lipoatrophy for people who are starting their first treatment should now be low. Newer drugs do not cause this side effect, and increased monitoring should pick this up if you are using older drugs like AZT.

Role of other HIV drugs

Some studies report a higher risk when d4T or AZT are used with protease inhibitors. There is an even higher rate seen with combinations that include drugs from the three main classes: i.e. nukes, a PI and an NNRTI.

A US study called ACTG 5142 reported higher rates of fat loss in people using efavirenz compared to lopinavir/r. These findings are not fully understood.

Switching treatment

Switching d4T or AZT to either abacavir or tenofovir, or using other combinations of drugs, can reverse the fat lost in limbs. Reversing fat loss from the fat or buttocks appears to be more difficult, but this may be possible if you switch treatment at the first symptoms.

There may be a risk of viral load rebounding if you have resistance to other HIV drugs. Otherwise, switching is very safe.

Any reversal of the fat loss is likely to take at least six months to become noticeable. These symptoms developed slowly and if they are going to reverse this will also take time.

In studies where people switched to abacavir, the return of small amounts of leg fat (+ 0.3kg) was detected by scans at 6 months. It took about two years (+1.3kg) before these patients noticed a difference themselves.

New-Fill (Sculptra)

New-Fill (polylactic acid, PLA) has shown promising results in correcting the effect of facial fat loss and is approved in the US as a treatment for HIV-related lipoatrophy. Most people require 4-5 sets of injections but severe cases may require more sessions.

New-Fill does not replace fat but generates new collagen growth. The effect is that essentially your skin grows thicker, sometimes by up to 1cm. This process continues for months after the injections have finished.

New-Fill has also been used to correct fat lost on the soles of the feet.

There is already good access to New-Fill on the NHS in some of the larger HIV clinics in the UK. These include Brighton, Manchester, and any patient attending a London clinic. Since 2005, New-Fill has been available free on the NHS for any patient registered at a London clinic.

Access to treatment is clearly not equally available throughout the UK. Although access should continue to improve, you may have to lobby hard, or even change clinic in order to access this treatment.

Private treatment costs vary by clinic. Private treatment should ONLY be from a practitioner with experience of HIV-related lipoatrophy.

UK HIV treatment guidelines recommend that corrective treatment such as New-Fill or surgery should be provided on the NHS.

Bio-Alcamid

Bio-Alcamid is a ‘gore-tex’ filler. This can be injected in greater volumes than New-Fill, so that with severe facial lipoatrophy, only one or two treatments may be needed.

The effect is likely to be permanent, whereas New-fill requires top-up treatment every few years. However, Bio-Alcamid is currently only rarely available on the NHS, because it has not been well-studied in trials.

Autologous fat transfer (Coleman technique)

This process was an early intervention before New-Fill became available. Fat is collected from one part of your body - usually subcutaneous fat from the stomach - and is then transplanted to the face.

Fat that has accumulated as a result of lipodystophy, for example shoulder pad fat is not suitable for transplanting as it may continue to expand in a process that is not reversible with liposuction.

This is a more traumatic surgical procedure and the process is now less frequently used.

Other injectable substances

Most other approaches try to inject or implant material (fat or silicon) and hope it will stay in position. Very often, it disperses, moves or appears lumpy. Silicon injections are both dangerous and ineffective and were banned in the US many years ago, although a study of a new finer grade of silicon is ongoing in the US.

Further info
A US community site with information on lipoatrophy treatment
http://www.facialwasting.org