Long-term complications of antiretroviral therapy: lipoatrophy

The effective use of potent antiretroviral therapy has dramatically improved the life expectancy for HIV-infected individuals. Long-term complications of both HIV-infection and antiretroviral agents are therefore of increasing concern. Lipoatrophy (LA) or fat wasting is a complication most frequently associated with nucleoside reverse transcriptase inhibitors, thymidine analogues particularly. LA can be stigmatising and is associated with psychosocial complication. It can occur in isolation or as part of the 'metabolic' or 'lipodystrophy' syndrome, a triad of LA, fat accumulation and metabolic disturbance (insulin resistance and dyslipidaemia) with a subsequently increased risk of cardiovascular events. We aimed to review the definition, prevalence, pathogenesis, implications and treatment of HIV/highly active antiretroviral therapy-associated fat loss. We performed a review of PubMed, Medline and recent conference abstracts for information on LA. The current treatments available for treating LA are limited. Switching away from thymidine analogues can provide a small benefit but improvement is, at best, slow and partial. Specific medical therapies such as glitazones, metformin and stating have been disappointing to date. Surgical fillers can yield marked results but are costly, time consuming and only of value for facial LA, not other sites. Ultimately, prevention of this condition is the best approach by avoiding thymidine analogues wherever possible or careful monitoring with early switching away from these agents. New therapies to treat pre-existing fat loss are required.