Discussion
Lipoatrophy was reported in 32.3% patients and the isolated form predominated. Lesions usually occured on the face. The factors associated with different phenotypes of lipoatrophy sometimes differed from those reported in other studies.
Unlike the data reporting the frequency of isolated lipohypertrophy[7] or mixed syndrome[8–11] during HAART, isolated lipoatrophy was reported as the most frequent anomaly in fat distribution in our patients. Precision concerning the clinical forms of lipoatrophy is often limited. Some studies reported a lower frequency of lipoatrophy: 9.8% in Rwanda,[8] 13% in France,[9] and 21% in Spain,[11] while the mixed syndrome was were frequent: 19% in Rwanda,[8] 27% in France,[9] and 24% in Spain.[11] Similar to our study, a Korean study[2] reported a frequency of isolated lipoatrophy of 24.3%.[2] The incidence of lipoatrophy in studies may be influenced by the variability of diagnosis criteria. Contrary to studies using specific criteria based on anthropometric[8,11] imaging or absorptiometry[7] assessment, we performed an inspection diagnosis which is likely to underestimate the frequency of anomalies in fat distribution. Compared to our findings, the reduced frequency of isolated lipoatrophy in some European cohorts could be related to the less frequent use of stavudine[9,11] as well as their short exposure to HAART;[9] this last condition supports why in Rwanda, despite the most frequent use of stavudine, isolated lipoatrophy was less frequent.[8] Similarly, the propensity to use protease inhibitors (PIs) justifies a greater frequency of mixed forms in European cohorts. In the French study, only patients receiving regimens containing PIs were included.[9]
Factors associated with lipoatrophy are sometimes different in the literature. Most studies agree that d4T is an important factor associated with lipoatrophy;[2,6,9,11–13] despite its less frequent use (35.7%), the prevalence of lipoatrophy was higher in our cohort than the Rwanda and South Africa cohorts who were using more than 90% of HAART regimens containing d4T. This finding may be partly explained by further exposure of our patients to the regimen. This condition is often associated with the occurrence of lipoatrophy[2,6,12] and justifies the opinion to reconsider further continuation of d4T after 12 months of use. Moreover, in contrast to our finding concerning the higher frequency of mixed syndrome during the use of d4T, a French study reported an association with isolated lipoatrophy.[11] The role of PIs in the occurrence of lipoatrophy is not univocal: the French study reported an association of saquinavir (SQV) with lipoatrophy or mixed syndrome; while in our survey, lopinavir boosted with ritonavir (LPV/r) was associated with mixed syndrome. Our finding could be explained because LPV/r was the single PI used in our cohort.[11]
Demographic, anthropometric, and behavioral factors associated with lipoatrophy are also variously reported. Similar to a Canadian study,[4] we found an association between female sex and mixed syndrome. Age greater than 42 years was also an associated factor. The trend to central adiposity with aging, a phenomenon more pronounced in women consecutive to hormonal influence, may promote such a phenotype.[14] Smoking and practice of physical activity were other factors associated with mixed syndrome. On the other hand, male sex and not being overweight were associated with isolated lipoatrophy as reported in Canadian[4] and Danish surveys.[12] The inverse relationship between fat tissue size and earlier visibility of lipoatrophy makes the observation of lipoatrophy phenotype easier in these conditions.[11] A Japanese study found an inverse relationship between fat tissue size and aging in men.[14] However, an association between female sex and lipoatrophy was found by other authors.[2,9]
The frequency of facial lipoatrophy is consistent with most data, probably due to the reduced thickness of the fatty tissue on the face. Unfortunately, facial lipoatrophy contributes more to stigma because it is not concealable. To this end, strategies for facial fillers are recommended. These methods are unavailable in developing countries. However, according to the Antiprotéases Cohorte study, facial lipoatrophy takes second position next to the lower limbs, after 2 years of follow-up.[10]
J Int Assoc Provid AIDS Care. 2014;13(2):184-187. © 2014 Sage Publications, Inc.
