Lipodystrophy in the patient with HIV: social, psychological, and treatment considerations

Approximately 1.3 million people in the United States and an estimated 33.2 million worldwide are infected with HIV. In the past, HIV/AIDS was considered to be uniformly fatal. With the introduction of highly active antiretroviral therapy (HAART), HIV has become a chronic, manageable disease in countries that are able to provide this therapy. The preservation of lives has not been without complications. In these patients, metabolic and stereotypical body disfiguring fat changes have emerged and have been lumped under the term lipodystrophy. Lipoatrophy and fat accumulation are generally thought to be separate yet overlapping phenomena. The prevalence rates for lipoatrophy may be as high as 25% to 38%; estimates for fat accumulation vary widely (from 14%-63%). Far from being "purely cosmetic," these fat changes can have a profoundly negative social and psychological impact, causing patients to feel disfigured, isolated, and stigmatized. Further, lipodystrophy may also negatively impact compliance with HAART. While there is evidence that the use of new HIV medications can prevent the development of these fat changes, many patients already manifest fat abnormalities; switching HAART, especially after lipodystrophy has progressed, offers only limited benefit. In addition, many resource-poor nations continue to rely on older HAART out of necessity. Because of this, methods are needed to address disfiguring body shape changes. The authors review the prevalence of lipoatrophy and lipohypertrophy, focusing on the impact on patients as well as reviewing available treatment options.