Management of morphologic changes during antiretroviral therapy: insights from etiology

Graeme Moyle MD MBBS, Christine Baldwin BSc Dip Diet
from HIV/AIDS Annual Update 2002

It is now more than two years since the widespread recognition of the metabolic and morphologic changes observed during antiretroviral therapy. The characteristic morphologic changes observed are highly stigmatising to individuals and may lead to consideration of delayed initiation of antiretroviral therapy, modification of established therapy to alternative regimens, or discontinuation of therapy to prevent or attempt to manage the problems.

Debate continues as to the possible linkage of the main components of the syndrome and indeed as to whether several different, overlapping syndromes may exist. The main components, which may be observed individually or in combination in persons on antiretroviral therapy, include:

  • dyslipidaemia with elevated total cholesterol, low high-density-lipoprotein (HDL) cholesterol, and triglycerides, with increased lipid cycling or turnover
  • insulin resistance with hyperglycaemia, particularly in individuals with a family history of type two diabetes mellitus
  • visceral, breast, and/or local fat accumulation
  • generalised diminution of subcutaneous fat mass, possibly with fat cell loss

Other metabolic and physical changes may also be present in patients receiving long-term antiretroviral therapy, including raised serum lactate, low bone mineral density, avascular necrosis of the hip, hypogonadism, and hypertension. The relationship of these problems to other metabolic and morphologic changes remains to be elucidated.

A clinical case definition has now been developed, based on physician and patient agreement regarding significant and characteristic morphologic changes together with the results of routine blood tests and specialist computed tomography (CT) and dual-energy x-ray absorptiometry (DEXA) investigations. This will potentially enable more homogeneous populations to be studied and comparisons to be made between intervention studies. However, this methodology is not suitable for routine clinical use.

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