|Lipodystrophy (fat redistribution)—general information
||See below for specific associations.
Trunk and limb fat initially increases within a few months of start of ART; peripheral fat wasting may not begin to appear for 12 to 24 months.
1%–33%, perhaps more common in adolescents than prepubertal children
Longer duration of ART
||Can occur in the absence of ART, but most associated with PIs and EFV;
EFV also associated with gynecomastia and breast hypertrophy
Central fat accumulation with increased abdominal girth, which may include dorsocervical fat pad (buffalo hump) and/or gynecomastia in males or breast hypertrophy in females. The appearance of central lipohypertrophy is accentuated in the presence of peripheral fat wasting (lipoatrophy).
|Up to 25%
||Obesity before initiation of therapy
Calorically appropriate, low-fat diet and exercise.
|Calorically appropriate, low-fat diet and exercise, especially strength training.
Smoking cessation (if applicable) to decrease future CVD risk.
Data are insufficient to allow the Panel to safely recommend use of any of the following modalities in children: recombinant human growth hormone, growth hormone-releasing hormone, metformin, thiazolidinediones, anabolic steroids, or liposuction.
||Most associated with thymidine analogue NRTI (d4T > ZDV)
Thinning of subcutaneous fat in face, buttocks, and extremities, measured as decrease in trunk/limb fat by DXA or triceps skinfold thickness. Preservation of lean body mass distinguishes lipoatrophy from HIV-associated wasting.
|Risk low (up to 15%) in patients not treated with d4T or ZDV
||d4T and ZDV
Obesity before ART
Avoid use of d4T and ZDV.
Patient self-report and physical exam are the most sensitive methods of monitoring lipoatrophy.
|Switch from d4T or ZDV to other NRTIs if possible without loss of virologic control.
Data are insufficient to allow the Panel to safely recommend use of any of the following modalities in children: injections of poly-L-lactic acid, recombinant human leptin, autologous fat transplantation, or thiazolidinediones.