Prospective evaluation of the effects of antiretroviral therapy on body composition in HIV-1-infected men starting therapy
Mallon, Patrick WGa,b; Miller, Johnb; Cooper, David Aa; Carr, Andrewb
From the aNational Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney and the bHIV, Immunology and Infectious Diseases Clinical Services Unit, St Vincent's Hospital Sydney Ltd., Sydney, Australia.
Correspondence to Dr Patrick W.G. Mallon, NCHECR, 376 Victoria Street, Darlinghurst, Sydney NSW 2010, Australia. Tel: +61 2 9332 4648; fax: +61 2 9332 1837; e-mail: Pmallon@nchecr.unsw.edu.au
Received: 23 May 2002; revised: 22 November 2002; accepted: 5 December 2002.
Objective: Little prospective data are published on the natural history of HIV-associated lipodystrophy (HIVLD) in individuals beginning their first antiretroviral regimen. To investigate this a study was designed to explore changes in body composition occurring with antiretroviral therapy.
Study design: A non-randomized, prospective, exploratory study of 40, HIV-infected men, naive to treatment, beginning antiretroviral therapy. Regular assessments of body composition, and metabolic and immunological parameters were performed.
Results: Mean follow-up was 96 (SD 45) weeks of therapy. There were increases in limb fat, central abdominal fat and lean mass over the initial 24 weeks of therapy followed by a selective, progressive loss of limb fat from week 24. There was a median 13.6% [interquartile range (IQR), 0.9–26.3] loss of limb fat per year from week 24 onwards. Treatment with stavudine, higher baseline HIV RNA, higher baseline ‘T’ score and lower week 24 lean mass were associated with higher rate of limb fat loss from week 24. In multivariate analysis, treatment with stavudine was the strongest independent factor associated with rate of limb fat loss (P = 0.05). Hypercholesterolaemia developed early in treatment, whereas hypertriglyceridaemia, hyperinsulinaemia and decreased bone mineral density developed later. The largest changes in CD4 cell counts and HIV viral load, seen early into treatment, were associated with gain rather than loss of fat.
Conclusions: This is the first prospective study demonstrating that treatment with antiretrovirals results in progressive, selective loss of limb fat. Loss of limb fat occurred after the period of most intense immune restoration, making an immune aetiology unlikely.
Individuals receiving antiretroviral therapy for the treatment of HIV-1 infection have experienced peripheral lipoatrophy , gain in visceral fat , hyperlipidaemia and insulin resistance, all of which have been grouped under the common heading of HIV-associated lipodystrophy (HIVLD).
The pathogenesis of HIVLD is likely to involve numerous mechanisms, such as the inhibition of DNA polymerase gamma in mitochondria by nucleoside reverse transcriptase inhibitors (NRTIs) leading to mitochondrial dysfunction in fat [3,4], abnormalities of fat differentiation resulting from the effects of protease inhibitors on transcription factors such as sterol regulatory element-binding protein-1 (SREBP-1) [5,6] and increased apoptosis of fat cells secondary to these many insults . Changes in immune status resulting from therapy, and the effects of secondary cytokine activation on fat tissue, could explain some changes seen in HIVLD  although evidence to support this view is lacking.
Cross-sectional cohorts have shown an association between HIVLD and older age, lower baseline CD4 cell counts, the use of and duration of use of protease inhibitors (PI) and of NRTIs [9–14] particularly when PIs and NRTIs are used in combination . Although the syndrome is well described, a lack of objective, prospective data prevents identification of possible primary and secondary defects. In one prospective study, any form of patient- or physician-reported lipodystrophy was seen in 17% of individuals at 18 months , but the study only included individuals taking PI-containing regimens.
We hypothesised that lipoatrophy occurs as a result of treatment with, and duration of, antiretroviral therapy, rather than being purely an immune phenomenon. To explore this hypothesis, we studied a cohort of antiretroviral-naive, HIV-infected men starting a variety of antiretroviral regimens, to determine changes in body composition resulting from therapy, and factors associated with these changes.
HIV-infected men, referred by their treating physicians, were sequentially recruited from the HIV Clinics of St Vincent's Hospital, Sydney, Australia. All patients had documented HIV-1 infection, were at least 18 years old, had no active AIDS-defining illness, no previous antiretroviral exposure and were at a stage of their illness where their treating physicians considered antiretroviral therapy appropriate. As this was a non-randomized study, the treating physician made decisions regarding the components of baseline antiretroviral regimens, and any subsequent treatment changes. All patients provided written, informed consent after approval of the study by the Human Research Ethics Committee.
Baseline demographics were collected. The following assessments were performed at baseline, weeks 12, 24 and then every 24 weeks thereafter; CD4+ lymphocyte counts, plasma HIV RNA, fasting total cholesterol, estimated low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglyceride, glucose and insulin [1,15].
Total and regional body composition was quantified at screening, and at weeks 12, 24, 48 and every 48 weeks thereafter by dual-energy X-ray absorptiometry (DEXA) (Lunar DPXL; Madison, Wisconsin, USA) at a single reading site. Estimates of central abdominal fat (CAF) and spinal bone mineral density (represented by ‘T’ score) were determined from a central window measurement [1,15].
All analyses were by intention-to-treat and included follow-up data on all subjects who started their treatment regardless of subsequent treatment changes. The primary endpoint was change in limb fat measured by DEXA with secondary endpoints of changes in CAF, total cholesterol and estimated LDL cholesterol, triglycerides, glucose, insulin and ‘T’ score. Data were collected on a specifically designed database (Logicielle, Sydney, Australia) and non-parametric analyses were applied. Paired comparisons were analysed using the Wilcoxon signed rank test, unpaired comparisons using the Mann–Whitney test and correlations between sets of variables using Spearman rank correlation coefficient tests. The Kruskal–Wallis test was used to compare three group samples. Simple and multiple regression analyses were performed to examine the relationship between variables. P values of less than 0.05 were considered significant.
Forty patients were recruited between July 1997 and May 2000 with analysis performed in December 2001. At the time of analysis, all patients were alive, 90% of the cohort had completed 96 weeks of therapy and 50% had completed 144 weeks of therapy.
All median baseline metabolic parameters were within normal limits (Table 1), as were body mass index (BMI) and bone mineral density. Almost half the cohort received a regimen containing a PI, with indinavir being the most common PI used. Five subjects received a regimen containing both PIs and non-nucleoside reverse transcriptase inhibitors (NNRTI). Roughly equal numbers were prescribed one of the three most common dual NRTI backbone regimens at that time: didanosine and stavudine, stavudine and lamivudine, and zidovudine and lamivudine.
Over the course of the study, 16 (40%) subjects changed therapy. Four (10%) subjects changed class from a PI to a NNRTI-containing regimen an average of 23 (range 12–36) months into the study. One subject changed from a PI to a NNRTI-containing regimen due to virological failure 2 years into the study. All remaining changes were secondary to side effects. The most common drugs involved were stavudine with 11 changes after a mean of 7 [3–12] months of treatment (six secondary to neuropathy, one secondary to symptomatic lactic acidaemia, one secondary to adherence problems and three for side effects not otherwise specified), didanosine (ddI) with five changes after a mean of 10 (3–24) months (three secondary to neuropathy, one secondary to nausea and one for other side effects), and indinavir with four changes after a mean of 8 (3–12) months (two secondary to renal calculi, one secondary to paronychia and one secondary to other side effects). No subject changed therapy as a result of changes in body composition.
Immunological and virological responses to therapy
Seventy percent of the cohort achieved viral load < 400 copies/ml by week 12, with no significant change seen between weeks 12 and 144 (Fig. 1b). At the time of analysis, 82% of the cohort achieved an undetectable viral load (HIV RNA < 400 copies/ml). Median baseline CD4 cell count was 246 × 106 cells/l (range 0 to 836 × 106 cells/l). The largest rise in median CD4 lymphocyte count occurred by week 24 (median increase of 126 × 106 cells/l, P < 0.0001), with a further significant rise between weeks 24 and 144 (increase of 56 × 106 cells/l, P < 0.05).
There was a significant rise in BMI (22.5 to 24, P < 0.05) and lean mass (3% rise from baseline, P < 0.01) by week 12, which was sustained to week 48. At week 96 BMI had decreased to a level not significantly different from baseline. Total body fat increased by median 20% to week 24 (P < 0.001) with no significant changes from week 24 onwards.
There was an increase in limb fat (median 5.6 versus 6.9 kg), CAF (1.0 versus 1.3 kg) and lean mass (52.5 versus 54.7 kg) to week 24 coinciding with the largest changes in CD4 and HIV RNA (Figs 1a and 2a). From week 24 onwards there was a selective, progressive loss of limb fat with median limb fat mass at weeks 96 and 144 being significantly less than baseline (median loss of 1.6 and 3.0 kg, respectively). During the initial period, 57% patients experienced greater than 10% gain in limb fat mass. Subsequently, however, 46% patients lost more than 10% limb fat mass and 48% patients lost at least 1 kg between baseline and week 96. From week 24, there was a median 13.6% [interquartile range (IQR), 0.9–26.3] loss of limb fat per year of treatment. This loss occurred after the period of greatest change in CD4 and HIV RNA (Fig. 1).
Older age correlated with a lower baseline limb fat. Higher baseline CAF and truncal fat correlated with higher baseline limb fat. The biggest gains in limb fat from baseline to week 24 were seen in those with higher baseline CAF and truncal fat, higher baseline HIV RNA and higher baseline ‘T’ scores. When baseline and week 24 patient, treatment, immune, morphological and metabolic factors were analysed, subjects treated with stavudine, those with higher baseline HIV RNA, higher baseline ‘T’ score and higher week 24 lean mass had a significantly greater rate of loss of limb fat from week 24 (percentage loss per year) (Tables 2–4). Multivariate analysis revealed use of stavudine to be associated with a significantly increased rate of loss of limb fat (P = 0.05).
Central abdominal fat
In contrast to limb fat, after an initial increase to week 24, CAF was maintained after week 24, remaining significantly greater than baseline out to week 144 (Fig. 2b). Baseline factors predicting larger mass of CAF at week 24 included higher baseline total fat, limb fat, truncal fat and CAF, higher insulin concentrations and higher BMI (Table 2). Factors associated with a greater percentage change in CAF between baseline and week 24 included lower baseline cholesterol and CD4 cell count and higher baseline HIV RNA. Subjects with more CAF at week 24 also had significantly higher week 24 truncal, limb and total fat, higher cholesterol, triglycerides, insulin, and lower HDL cholesterol and a higher BMI (Table 3). A greater change in CD4 cell count from baseline correlated with changes in limb fat, truncal fat, CAF and total fat. Those taking a PI-containing regimen had significantly higher and those taking a NNRTI regimen had significantly lower CAF at week 24.
Bone mineral density
The ‘T’ score rose slightly to week 24 and then fell significantly to week 48 remaining significantly lower than baseline out to week 144. The percentage of the cohort with ‘T’ scores less than −1 (consistent with osteopenia) rose from 13% at baseline to 22% at week 144. There was little change in the number of the subjects with ‘T’ scores less than −2.5 consistent with osteoporosis (1 at baseline, 2 at week 144).
Changes in metabolic parameters are illustrated in Figure 3. Fasting total cholesterol and estimated LDL cholesterol rose significantly early into treatment with the largest rise occurring by week 12 (Fig. 3a). Both remained significantly higher than baseline out to week 144. In contrast triglyceride concentrations did not rise significantly until week 96 and remained elevated out to week 144 (Fig. 3b). Similarly, insulin concentrations rose late with significantly higher insulin concentrations occurring at week 144 (Fig. 3b). Changes in fasting insulin were not significantly different between those prescribed PI-containing regimens [median, 1.2 mmol/l per year (IQR, −0.87 to 3.27)] and those prescribed PI-sparing regimens [0.65 mmol/l per year (IQR −0.7 to 2)].
The change in total and LDL cholesterol per year of treatment was 0.44 and 0.24 mmol/l, respectively. In a multivariate analysis of baseline variables, treatment with PIs (P = 0.006), lower baseline cholesterol (P = 0.02), and lower baseline lean mass (P = 0.04) were independently associated with greater increases in total cholesterol. Similarly, use of PIs (P = 0.002) and lower baseline LDL (P = 0.04) were associated with the largest rises in LDL cholesterol.
The change in triglycerides concentrations was 0.14 mmol/l per year of treatment. No baseline factor determined change in triglyceride, although those with greater change in cholesterol per year also had significantly larger rises in triglycerides per year (P = 0.01).
HDL cholesterol rose by 0.1 mmol/l at week 24 (P < 0.01) but the rise was not sustained past week 96. Fasting glucose concentrations did not change (4.7 mmol/l at baseline versus 4.85 mmol/l at week 144).
The complexity of the mechanisms underlying HIVLD is reflected in the results of this exploratory study. Most of the components of HIVLD, such as central fat accumulation, peripheral lipoatrophy and hyperlipidaemia were observed. Contributions by drug classes and specific drugs, in addition to immunological and virological responses to therapy, were all shown to have some correlation with changes in body composition. From these results, a sequence of events begins to emerge, providing an insight into possible primary and secondary events in the development of HIVLD. Of importance, these results reveal trends that run counter to some currently held theories about the possible mechanisms underlying HIVLD.
The gains in both central abdominal fat and limb fat seen during the first 24 weeks of treatment could be explained by general improvements in health and nutrition associated with treatment of HIV viraemia and reversal of the associated catabolic state. The simultaneous increase in lean mass also seen during this period support this viewpoint, suggesting that these changes result from general improvements in nutrition rather than a fat-specific process.
The gain in CAF during the initial 24 weeks of therapy may reflect the visceral fat accumulation reported in HIVLD . From week 24 onwards, there was an obvious selective, progressive loss of limb fat whereas both CAF and lean mass were maintained (Figs 1 and 2). This likely represents the lipoatrophy that is characteristic of HIVLD. Maintained levels of CAF in the presence of limb fat loss (Fig. 1) could result in the central fat becoming more pronounced clinically to patients or physicians as limb fat declined.
Of interest is the correlation noted between CAF and limb fat. Although by 3 years both gain in central fat and loss of limb fat are present, the two processes do not appear to be occurring simultaneously and may be part of separate aetiologies – the increase in CAF probably in response to nutritional improvement (and therefore a secondary effect of drug treatment), whereas the loss of limb fat was probably a result of long-term antiretroviral drug use. However, excess fat accumulation resulting from changes in nutritional requirements alone would be expected to decrease over time as the body gains muscle mass. The fact that this fails to occur in this cohort may indicate that the persistent accumulation of abdominal fat seen after week 24 is a reflection of a pathological process. Whether this is related to immune restoration, continued drug exposure or other process is unclear from this study.
Loss of limb fat, however, developed in the absence of significant changes in HIVVL, and after the largest change in CD4 cell count had already occurred (Fig. 1a and 1b). This runs contrary to the hypothesis that HIVLD is part of a cytokine-driven ‘immune reconstitution’ phenomenon [8,16]. Indeed, during the period of most intense immune recovery, there was actually a gain, rather than a loss, of both limb fat and CAF.
Complex relationships between morphological and metabolic changes are apparent from this study. Those with higher baseline cholesterol values gained less limb fat and CAF to week 24 (Table 2). A first impression may be that these subjects already have high baseline body fat deposits, thus explaining the higher cholesterol values and lower relative fat gains. However this was not the case, as no significant correlations existed between baseline cholesterol levels and mass of total or compartmental body fat (data not shown).
The importance of the cholesterol values is reflected in their strong association with subsequent loss of limb fat (Table 3). Such an association has previously been reported . There are marked inter-individual variations in the function of adipose tissue, with evidence supporting a genetic basis for this variation . If higher cholesterol levels reflect poorly functioning adipose tissue, these individuals may be at higher risk of further adipose tissue dysfunction, resulting from the additional and continuing insults from antiretrovirals on adipose tissue (e.g. SREBP-1c) [5,6] or mitochondrial function . This could explain the changes seen in this cohort.
Higher insulin concentrations associated with high CAF mass, seen in this study, is an association that has been well described in HIV-infected  and uninfected populations . Other PI- induced mechanisms of insulin resistance, such as those involving dysfunction of the GLUT-4 glucose transporter [21,22], result in an acute insulin resistance. Although in vitro evidence exists to support such a mechanism, such an acute process should result in high insulin concentrations early in the course of treatment. This was not seen in this study, with hyperinsulinaemia occurring later into treatment.
Although the most detailed prospective study to date, the results from this study should be viewed in the context of study limitations. It could be argued that the fact that this was a non-randomized study, with no untreated controls, using various antiretroviral regimens, in a cohort of male only patients is a limitation. In addition, the use of total body DEXA to estimate CAF and bone mineral density is imperfect. Although significant associations were detected, these should be viewed in the context of the number of subjects involved in the study. It could be argued that the large number of comparisons studied and the multiple data points used leaves the results prone to false positives, although non-parametric analyses were employed in an attempt to limit this.
The number of treatment changes may or may not be viewed as a limitation. Treatment changes happen frequently in routine practice and as such, this study may provide a more accurate description of the development of HIVLD in clinical practice. In addition, development of HIVLD was not used as a reason for changing treatment. The impact of treatment changes on the overall analysis was minimal. For example, there were no significant differences in the rate of limb fat loss in those who stopped stavudine, nor in the accumulation of CAF in those who stopped indinavir (data not shown).
Objective changes in body composition correlating with HIV associated lipodystrophy [1,2] only became readily apparent after 2 years of antiretroviral treatment in this cohort. This has consequences with respect to published studies alluding to the metabolically friendly profile of certain drugs or drug combinations , which have a relatively short follow-up period. Importantly, this study shows how the development of lipoatrophy is relatively independent of changes in immune function, being more a product of continued exposure to antiretroviral drugs.
The authors wish to thank the patients for their participation in the study. We also wish to acknowledge the help with the design of the statistical analysis provided by Dr Matthew Law from the National Centre in HIV Epidemiology and Clinical Research, Sydney, Australia.
Sponsorship: The National Centre in HIV Epidemiology and Clinical Research is funded by the Commonwealth Department of Health and Aged Care through the Australian National Council on AIDS, Hepatitis C and Related Diseases and its Research Advisory Committee.
P.W.G.M. is supported by funds from the National Heart Lung and Blood Institute of the National Institutes of Health, grant number RO1 HL65953-01.
1.Carr A, Samaras K, Burton S, Law M, Freund J, Chisholm DJ, et al
. A syndrome of peripheral lipodystrophy, hyperlipidaemia and insulin resistance in patients receiving HIV protease inhibitors. AIDS
2.Miller KD, Jones E, Yanovski JA, Shankar R, Feuerstein I, Falloon J. Visceral abdominal-fat accumulation associated with the use of indinavir. Lancet
3.Shikuma CM, Hu N, Milne C, Yost F, Waslien C, Shimizu S, et al
. Mitochondrial DNA decrease in subcutaneous adipose tissue of HIV infected individuals with peripheral lipoatrophy. AIDS
4.Brinkman K, Smeitink JA, Romijn HA, Reiss P. Mitochondrial toxicity induced by nucleoside-analogue reverse-transcriptase inhibitors is a key factor in the pathogenesis of antiretroviral-related lipodystrophy. Lancet
5.Caron M, Auclair M, Vigouroux C, Glorian M, Forest C, Capeau J. The HIV protease inhibitor indinavir impairs sterol regulatory element-binding protein-1 intranuclear localisation, inhibits preadipocyte differentiation, and induces insulin resistance. Diabetes
6.Dowell P, Flexner C, Kwiterovich P, Lane MD. Suppression of preadipocyte differentiation and promotion of adipocyte death by HIV protease inhibitors. J Biol Chem
7.Domingo P, Matias-Guiu X, Pujol R P, Francia E, Lagarda E, Sambeat M A, et al
. Subcutaneous adipocyte apoptosis in HIV-1 protease inhibitor-associated lipodystrophy. AIDS
8.Ledru E, Christeff N, Patey O, de Truchis P, Melchior J-C, Gougeon M-L. Alteration of tumor necrosis factor-( T-cell homeostasis following potent antiretroviral therapy: contribution to the development of human immunodeficiency virus-associated lipodystrophy syndrome. Blood
9.van der Valk M, Gisolf EH, Wit FWNM, Japour A, Weverling GJ, Danner SA on behalf of the Promethus study group. Increased risk of lipodystrophy when nucleoside analogue reverse transcriptase inhibitors are included with protease inhibitors in the treatment of HIV-1 infection. AIDS
10.Martinez E, Mocroft A, Garcia-Viejo MA, Perez-Cuevas JB, Blanco JL, Mallolas J, et al
. Risk of lipodystrophy in HIV-1-infected patients treated with protease inhibitors: a prospective cohort study. Lancet
11.Thiebaut R, Daucourt V, Mercie P, Ekouevi DK, Malvy D, Morlat P, et al. Lipodystrophy, metabolic disorders, and human immunodeficiency virus infection: Aquitaine Cohort, France, 1999. Clin Infect Dis
12.Lichtenstein KA, Ward DJ, Moorman AC, Delaney KM, Young B, Palella FJ Jr, et al
. Clinical assessment of HIV-associated lipodystrophy in an ambulatory population. AIDS
13.Carr A, Miller J, Law M, Cooper DA. A syndrome of lipoatrophy, lactic acidaemia and liver dysfunction associated with HIV nucleoside analogue therapy: contribution to protease inhibitor-related lipodystrophy syndrome. AIDS
14.Boufassa F, Dulioust A, Lascaux AS, Meyer L, Boue F, Delfraissy JF, et al
. Lipodytrophy in 685 HIV-1-treated patients: influence of antiretroviral treatment and immunovirological response. HIV Clin Trials
15.Carr A, Samaras K, Thorisdottir A, Kaufmann G, Chisholm DJ, Cooper DA. Diagnosis, prediction and natural course of HIV protease inhibitor-associated lipodystrophy, hyperlipidaemia and diabetes mellitus. Lancet
16.Mynarcik D C, McNurlan M A, Steigbigel R T, Fuhrer J, Gelaot MC. Association of severe insulin resistance with both loss of limb fat and elevated serum tumor necrosis factor receptor levels in HIV lipodystrophy. J Acquir Immune Defic Syndr
17.Bogner JR, Vielhauer V, Beckmann RA, Michl G, Wille L, Salzberger B, et al
. Stavudine versus zidovudine and the development of lipodystrophy. J Acquir Immune Defic Syndr
18.Miserez AR, Muller PY, Barella L, Schwietert M, Erb P, Vernazza PL, et al
. A single-nucleotide polymorphism in the sterol-regulatory element-binding protein 1c gene is predictive of HIV-related hyperlipoproteinaemia. AIDS
19.Gan S K, Samaras K, Thompson C, Kraegen E, Carr A, Cooper D, et al
. Correlations between intramyocellular lipid, visceral fat and insulin sensitivity: a study of HIV positive subjects with and without peripheral lipodystrophy. Diabetes
20.Carey DG, Jenkins AB, Campbell LV, Freund J, Chisholm DJ. Abdominal fat and insulin resistance in normal and overweight women. Diabetes
21.Noor MA, Lo JC, Mulligan K, Schwarz JM, Halvorsen RA, Schambelan M, et al
. Metabolic effects of indinavir in healthy HIV-seronegative subjects. AIDS
22.Murata H, Hruz P W, Mueckler M. The mechanism of insulin resistance caused by HIV protease inhibitor therapy. J Biol Chem
23.Dube MP, Qian D, Edmondson-Melancon H, Sattler FR, Goodwin D, Martinez C, et al
. Prospective, intensive study of metabolic changes associated with 48 weeks of amprenavir-based antiretroviral therapy. Clin Infect Dis
This article has been cited 137 time(s).
AIDS Research and Human RetrovirusesEffect of Different Antiretroviral Drug Regimens on Body Fat Distribution of HIV-Infected South African WomenAIDS Research and Human Retroviruses
International Journal of Std & AIDSEndocrine and metabolic abnormalities among HIV-infected patients: A current reviewInternational Journal of Std & AIDS
Endocrine ReviewsAdiposity and Insulin Resistance in Humans: The Role of the Different Tissue and Cellular Lipid DepotsEndocrine Reviews
Effect of treatment interruption monitored by CD4 cell count on mitochondrial DNA content in HIV-infected patients: a prospective study
Journal of Antimicrobial ChemotherapyA randomized trial to investigate the recycling of stavudine and didanosine with and without hydroxyurea in salvage therapy (RESTART)Journal of Antimicrobial Chemotherapy
Rosiglitazone for HIV-1 lipoatrophy
MitochondrionPotential roles for uncoupling proteins in HIV lipodystrophyMitochondrion
Glucose metabolism, lipid, and body fat changes in antiretroviral-naive subjects randomized to nelfinavir or efavirenz plus dual nucleosides
Clinical Infectious DiseasesMetabolic syndrome in HIV-infected patients from an urban, midwestern US outpatient populationClinical Infectious Diseases
Clinical Infectious DiseasesChanges in Body Composition with Ritonavir-Boosted and Unboosted Atazanavir Treatment in Combination with Lamivudine and Stavudine: A 96-Week Randomized, Controlled StudyClinical Infectious Diseases
Hiv Clinical Trials
Update on HIV lipodystrophy
Hiv Clinical Trials, 5(3):
Lipoatrophic men 44 months after the diagnosis of lipoatrophy are less lipoatrophic but more hypertensive
Hiv Medicine, 6(4):
Influence of rosiglitazone on flow-mediated dilation and other markers of cardiovascular risk in HIV-infected patients with lipoatrophy
Antiviral Therapy, 10(1):
Lipid disorders in patients with HIV-induced diseases
Presse Medicale, 34():
Clinical Microbiology and InfectionEfficacy and safety of an anti-retroviral combination regimen including either efavirenz or lopinavir-ritonavir with a backbone of two nucleoside reverse transcriptase inhibitorsClinical Microbiology and Infection
Southern African Journal of Hiv Medicine
Changes in Body Composition and Other Anthropometric Measures of Female Subjects on Highly Active Antiretroviral Therapy (Haart): A Pilot Study in Kwazulu-Natal, South Africa
Southern African Journal of Hiv Medicine, ():
Jaids-Journal of Acquired Immune Deficiency Syndromes
Do new protease inhibitors offer improved management options? Issues of PI tolerability and safety
Jaids-Journal of Acquired Immune Deficiency Syndromes, 35():
Methodological considerations in human studies of gene expression in HIV-associated lipodystrophy
Antiviral Therapy, 10():
Archives of Dermatology
Use of polylactic acid implants to correct facial lipoatrophy in human immunodeficiency virus 1-positive individuals receiving combination antiretroviral therapy
Archives of Dermatology, 142(3):
Longitudinal increases in waist circumference are associated with HIV-serostatus, independent of antiretroviral therapy
Expert Opinion on PharmacotherapyTreatment options for lipodystrophy in HIV-positive patientsExpert Opinion on Pharmacotherapy
Hiv MedicineEuropean AIDS Clinical Society (EACS) guidelines on the prevention and management of metabolic diseases in HIVHiv Medicine
Dermatologic ClinicsLipodystrophy SyndromesDermatologic Clinics
American Journal of Physiology-Endocrinology and MetabolismReducing plasma HIV RNA improves muscle amino acid metabolismAmerican Journal of Physiology-Endocrinology and Metabolism
Long-term safety and tolerability of the lamivudine/abacavir combination as components of highly active antiretroviral therapy
Drug Safety, 29(9):
American Journal of Clinical Nutrition
Micronutrients in HIV-positive persons receiving highly active antiretroviral therapy
American Journal of Clinical Nutrition, 85(2):
Expert Opinion on Drug Metabolism & ToxicologyToxic metabolic syndrome associated with HAARTExpert Opinion on Drug Metabolism & Toxicology
Hiv Clinical TrialsA Prospective Study of Body Fat Redistribution, Lipid, and Glucose Parameters in HIV-Infected Patients Initiating Combination Antiretroviral TherapyHiv Clinical Trials
Hiv Clinical TrialsA Meta-Analysis of Six Placebo-Controlled Trials of Thiazolidinedione Therapy for HIV LipoatrophyHiv Clinical Trials
MitochondrionMitochondrial dysfunction in AIDS and its treatmentMitochondrion
Jama-Journal of the American Medical Association
Metabolic and skeletal complications of HIV infection - The price of success
Jama-Journal of the American Medical Association, 296(7):
Dermatologic SurgerySafety and efficacy of poly-L-lactic acid injections in persons with HIV-associated lipoatrophy: The US experienceDermatologic Surgery
AIDS Patient Care and StdsAntiretroviral therapies associated with lipoatrophy in HIV-infected womenAIDS Patient Care and Stds
Hiv Clinical TrialsImprovements in Subcutaneous Fat, Lipid Profile, and Parameters of Mitochondrial Toxicity in Patients with Peripheral Lipoatrophy When Stavudine is Switched to Tenofovir (LIPOTEST Study)Hiv Clinical Trials
Plos OneIncreasing Rates of Obesity among HIV-Infected Persons during the HIV EpidemicPlos One
Clinical Infectious Diseases
The challenge of understanding articles about health-related quality of life
Clinical Infectious Diseases, 39(3):
Hiv Clinical Trials
Progression of lipodystrophy (LD) with continued thymidine analogue usage: Long-term follow-up from a randomized clinical trial (the PIILR study)
Hiv Clinical Trials, 5(4):
Pronounced lipoatrophy in HIV-infected men receiving HAART for more than 6 years compared with the background population
Hiv Medicine, 7(1):
International Journal of Clinical PracticeLong-term complications of antiretroviral therapy: lipoatrophyInternational Journal of Clinical Practice
Wiener Klinische WochenschriftPrevalence and risk factors for osteopenia/osteoporosis in an HIV-infected male populationWiener Klinische Wochenschrift
AIDS Research and Human RetrovirusesMitochondrial Oxidative Phosphorylation Protein Levels in Peripheral Blood Mononuclear Cells Correlate with Levels in Subcutaneous Adipose Tissue within Samples Differing by HIV and Lipoatrophy StatusAIDS Research and Human Retroviruses
Journal of Antimicrobial ChemotherapyEvolving perspectives on HIV-associated lipodystrophy syndrome: moving from lipodystrophy to non-infectious HIV co-morbiditiesJournal of Antimicrobial Chemotherapy
Current Hiv Research
Progenitor Cell Types in HIV-1 Infection: Bioactivity and Emerging Targets for Treatment
Current Hiv Research, 7(5):
Cervical lipomatosis in HIV-infected patients: a case-control study
Hiv Medicine, 8(1):
Journal of InfectionsuPAR associates to glucose metabolic aberration during glucose stimulation in HIV-infected patients on HAARTJournal of Infection
Clinical Infectious Diseases
The pharmacogenetics of antiretroviral therapy: A review of studies to date
Clinical Infectious Diseases, 39(1):
Journal of Antimicrobial ChemotherapyTherapeutic approaches to combating lipoatrophy: do they work?Journal of Antimicrobial Chemotherapy
Pathogenesis of lipodystrophy and lipid abnormalities in patients taking antiretroviral therapy
AIDS Reviews, 9(1):
Genetic analysis implicates resistin in HIV lipodystrophy
Clinical NutritionAntiretroviral therapy affects the composition of weight loss in HIV infection: Implications for clinical nutritionClinical Nutrition
European Journal of Clinical Investigation
Impact of antiretroviral therapy on visfatin and retinol-binding protein 4 in HIV-infected subjects
European Journal of Clinical Investigation, 36(9):
Scandinavian Journal of Infectious DiseasesAntiretroviral treatment of HIV infection: Swedish recommendations 2007Scandinavian Journal of Infectious Diseases
Journal of InfectionRisk of premature atherosclerosis and ischemic heart disease associated with HIV infection and antiretroviral therapyJournal of Infection
Epidemiology, Assessment, and Management of Excess Abdominal Fat in Persons with HIV Infection
AIDS Reviews, 12(1):
Jama-Journal of the American Medical Association
Growth hormone-releasing hormone in HIV-infected men with lipodystrophy - A randomized controlled trial
Jama-Journal of the American Medical Association, 292(2):
Muscle & NerveOxidative stress, chronic disease, and muscle wastingMuscle & Nerve
Effect of atazanavir and ritonavir on the differentiation and adipokine secretion of human subcutaneous and omental preadipocytes
Antiviral TherapyAdipocyte differentiation, mitochondrial gene expression and fat distribution: differences between zidovudine and tenofovir after 6 monthsAntiviral Therapy
Journal of Drugs in Dermatology
Monophasic, Cohesive-polydensified-matrix Crosslinking-technology-based Hyaluronic Acid Filler for the Treatment of Facial Lipoatrophy in HIV-infected Patients
Journal of Drugs in Dermatology, 9(6):
Clinical Infectious Diseases
Perirenal fat diameter measured by echography could be an early predictor of lipodystrophy in HIV type 1-infected patients receiving highly active antiretroviral therapy
Clinical Infectious Diseases, 39(2):
Clinical Infectious Diseases
CD4(+) cell count, viral load, and highly active antiretroviral therapy use are independent predictors of body composition alterations in HIV-infected adults: A longitudinal study
Clinical Infectious Diseases, 41():
Journal of Clinical Endocrinology & MetabolismApproach to the human immunodeficiency virus-infected patient with lipodystrophyJournal of Clinical Endocrinology & Metabolism
No effect of rosiglitazone for treatment of HIV-1 lipoatrophy: randomised, double-blind, placebo-controlled trial
New England Journal of Medicine
Medical progress - Cardiovascular risk and body-fat abnormalities in HIV-infected adults
New England Journal of Medicine, 352(1):
Journal of Clinical DensitometryReproducibility of DXA estimations of body fat in HIV lipodystrophy - Implications for clinical researchJournal of Clinical Densitometry
Evaluation of the HIV lipodystrophy case definition in a placebo-controlled, 144-week study in antiretroviral-naive adults
Antiviral Therapy, 11(2):
Journal of Antimicrobial ChemotherapyEvolving perspectives on HIV-associated lipodystrophy syndrome: moving from lipodystrophy to non-infectious HIV co-morbiditiesJournal of Antimicrobial Chemotherapy
Immunophenotype of HIV plus patients during CD4 cell-monitored treatment interruption: role of the IL-7/IL-7 receptor system
Pharmacogenetics of Adverse Effects Due To Antiretroviral Drugs
AIDS Reviews, 12(1):
MitochondrionRole of mitochondria in HIV lipoatrophy: insight into pathogenesis and potential therapiesMitochondrion
Antiretroviral therapy and the prevalence of osteopenia and osteoporosis: a meta-analytic review
AIDS Patient Care and StdsAssessment of Ultrasound for Use in Detecting Lipoatrophy in HIV-Infected Patients Taking Combination Antiretroviral TherapyAIDS Patient Care and Stds
Journal of Infectious Diseases
In vivo, nucleoside reverse-transcriptase inhibitors alter expression of both mitochondrial and lipid metabolism genes in the absence of depletion of mitochondrial DNA
Journal of Infectious Diseases, 191():
Nature Clinical Practice Endocrinology & MetabolismTherapy Insight: body-shape changes and metabolic complications associated with HIV and highly active antiretroviral therapyNature Clinical Practice Endocrinology & Metabolism
Diabetes Obesity & MetabolismAntiretroviral therapy and the human immunodeficiency virus - improved survival but at what cost?Diabetes Obesity & Metabolism
Transactions of the Royal Society of Tropical Medicine and HygieneWeight evolution in HIV-1 infected women in Rwanda after stavudine substitution due to lipoatrophy: comparison of zidovudine with tenofovir/abacavirTransactions of the Royal Society of Tropical Medicine and Hygiene
Jornal De PediatriaLipodystrophy in children and adolescents with acquired immunodeficiency syndrome and its relationship with the antiretroviral therapy employedJornal De Pediatria
Journal of Antimicrobial ChemotherapyPeripheral and visceral fat changes following a treatment switch to a non-thymidine analogue or a nucleoside-sparing regimen in HIV-infected subjects with peripheral lipoatrophy: results of ACTG A5110Journal of Antimicrobial Chemotherapy
Toxicologic PathologyThe Role of Protease Inhibitors in the Pathogenesis of HIV-Associated Lipodystrophy: Cellular Mechanisms and Clinical ImplicationsToxicologic Pathology
Clinical and Experimental ImmunologyLow plasma level of adiponectin is associated with stavudine treatment and lipodystrophy in HIV-infected patientsClinical and Experimental Immunology
British HIV Association (BHIVA) guidelines for the treatment of HIV-infected adults with antiretroviral therapy (2005)
Hiv Medicine, 6():
AIDS Patient Care and Stds
Psychometric properties of a lipodystrophy scale
AIDS Patient Care and Stds, 20(1):
Tropical Medicine & International HealthDeterminants of unplanned antiretroviral treatment interruptions among people living with HIV in Yaounde, Cameroon (EVAL survey, ANRS 12-116)Tropical Medicine & International Health
Social Science & Medicine"When in the body, it makes you look fat and HIV negative": The constitution of antiretroviral therapy in local discourse among youth in Kahe, TanzaniaSocial Science & Medicine
Arquivos Brasileiros De Endocrinologia E Metabologia
Bone mineral density in HIV-infected women taking antiretroviral therapy: a systematic review
Arquivos Brasileiros De Endocrinologia E Metabologia, 54(2):
Expert Opinion on Therapeutic Patents
Cardiovascular risk associated with antiretroviral therapy in IV-infected patients
Expert Opinion on Therapeutic Patents, 16():
Expert Opinion on PharmacotherapyStrategies in the treatment of HIV-1-associated adipose redistribution syndromesExpert Opinion on Pharmacotherapy
Hiv MedicineEarly changes in adipokine levels and baseline limb fat may predict HIV lipoatrophy over 2 years following initiation of antiretroviral therapyHiv Medicine
Bone alterations during HIV infection
New Microbiologica, 31(2):
Clinical Infectious Diseases
HIV-associated lipoatrophy: What are the kinder, gentler agents?
Clinical Infectious Diseases, 42(2):
Hiv Clinical Trials
Changes in body fat measured by DEXA in patients taking different formulations of stavudine
Hiv Clinical Trials, 6(6):
Hiv Clinical TrialsStavuldine but not Didanosine as part of HAART contributes to peripheral lipoatrophy: A substudy from the Antiretroviral regimen evaluation study (ARES)Hiv Clinical Trials
Hiv MedicineLipodystrophy and weight changes: data from the Swiss HIV Cohort Study, 2000-2006Hiv Medicine
Ultrasound in Medicine and BiologyComparability of echographic and tomographic assessments of body fat changes related to the hiv associated adipose redistribution syndrome (HARS) in antiretroviral treated patientsUltrasound in Medicine and Biology
Radiologia MedicaUltrasonographic assessment of lipodystrophy in HIV-1-infected patientsRadiologia Medica
Hiv MedicineEvolution of bone mineral density in AIDS patients on treatment with zidovudine/lamivudiine plus abacavir or lopinavir/ritonavirHiv Medicine
AIDS Patient Care and StdsTreatment Options for HIV-Associated Central Fat AccumulationAIDS Patient Care and Stds
Dyslipidemia and Adherence to the Mediterranean Diet in Croatian HIV-Infected Patients during the First Year of Highly Active Antiretroviral Therapy
Collegium Antropologicum, 33(2):
Scandinavian Journal of Infectious DiseasesBody composition changes in 308 Norwegian HIV-positive patientsScandinavian Journal of Infectious Diseases
Journal of Clinical VirologyMitochondrial DNA depletion in adipose tissue of HIV-infected patients with peripheral lipoatrophyJournal of Clinical Virology
HerzMetabolic syndrome and hyperlipidemia in HIV-positive patientsHerz
Hiv MedicineImpact of switching from zidovudine/lamivudine to tenofovir/emtricitabine on lipoatrophy: the RECOMB studyHiv Medicine
Bmc Infectious DiseasesEarly loss of bone mineral density is correlated with a gain of fat mass in patients starting a protease inhibitor containing regimen: the prospective Lipotrip studyBmc Infectious Diseases
Journal of NutritionSex, Smoking, and Socioeconomic Status Are Associated with Body Composition among Tuberculosis Patients in a Deuterium Dilution Cross-Sectional Study in Mwanza, TanzaniaJournal of Nutrition
Journal of Antimicrobial ChemotherapySwitching to lopinavir/ritonavir with or without abacavir/lamivudine in lipoatrophic patients treated with zidovudine/abacavir/lamivudineJournal of Antimicrobial Chemotherapy
Current Opinion in Infectious DiseasesWhat is HIV-associated lipodystrophy? Defining fat distribution changes in HIV infectionCurrent Opinion in Infectious Diseases
Current Opinion in Infectious DiseasesUse of recombinant human growth hormone in HIV-associated lipodystrophyCurrent Opinion in Infectious Diseases
JAIDS Journal of Acquired Immune Deficiency SyndromesBuffalo Hump Seen in HIV-Associated Lipodystrophy is Associated With Hyperinsulinemia But Not DyslipidemiaJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesMixed Patterns of Changes in Central and Peripheral Fat Following Initiation of Antiretroviral Therapy in a Randomized TrialJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesHigh Plasma Level of Interleukin-18 in HIV-Infected Subjects With LipodystrophyJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesRegional Adipose Tissue and Elevations in Serum Aminotransferases in HIV-Infected IndividualsJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesThe Effect of Individual Antiretroviral Drugs on Body Composition in HIV-Infected Persons Initiating Highly Active Antiretroviral TherapyJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesRedefining Lipodystrophy Syndrome: Risks and Impact on Clinical Decision MakingJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesLongitudinal Anthropometric Changes in HIV-Infected and HIV-Uninfected MenJAIDS Journal of Acquired Immune Deficiency Syndromes
AIDSMetabolic bone disease in HIV infectionAIDS
JAIDS Journal of Acquired Immune Deficiency SyndromesLongitudinal Anthropometric Patterns Among HIV-Infected and HIV-Uninfected WomenJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesLong-Term Subcutaneous Tissue Changes Among Antiretroviral-Naive Persons Initiating Stavudine, Zidovudine, or Abacavir With LamivudineJAIDS Journal of Acquired Immune Deficiency Syndromes
HIV; lipodystrophy; highly active antiretroviral therapy; densitometry; X-ray; adipose tissue; metabolic syndrome X
© 2003 Lippincott Williams & Wilkins, Inc.
Highlight selected keywords in the article text.