Lipodystrophy in Asia: Why Haven't We Phased Out d4T?

July 2011—Lipodystrophy—a condition in which fat on some areas of the body shrinks or increases—is one of the most potentially disfiguring side effects of antiretroviral therapy (ART). In severe cases, lipoatrophy, which involves fat reductions in the face and arms, and lipohypertrophy, which involves increases in fat on the abdomen or back of the neck, can lead to stigma and discrimination, and the fear of developing it can lead people with HIV to avoid starting treatment.

A recent study from the TREAT Asia HIV Observational Database (TAHOD) examined how common lipodystrophy is in Asia among people on ART, and what factors increased the risk for having it.¹ A total of 2,072 patients from 12 clinics in 12 Asian countries were included in the analysis. The researchers focused on patients who were reported by their doctors to have severe lipodystrophy, defined as disfiguring or obvious body shape changes.

Lipodystrophy was diagnosed in 217, or 10.5 percent, of those in the study at a median age of 36 years. The study found that there was an increased risk of lipodystrophy for those on ART for the longest periods of time (16 percent of those on treatment for longer than the median of 3.8 years; 5 percent of those on treatment for less than that period), or who were on the antiretroviral stavudine (d4T). Up to 19 percent of patients who ever took d4T had lipodystrophy, compared to 1 percent of those who never took the drug. Taking zidovudine or a protease inhibitor was associated with a lower risk of lipodystrophy compared to never taking those drugs.

These findings confirm those of other researchers that the use of d4T is a strong risk factor for the development of lipodystrophy in Asia. Although the World Health Organization recommended in 2010 that countries begin phasing out d4T, its low cost means that it continues to be one of the most commonly used drugs to treat HIV in resource-limited settings. The potential negative impact of lipodystrophy on long-term treatment success and program retention should play a greater role in the policies of national HIV programs, and outweigh the short-term benefits of a cheaper drug.

^1. Han SH, Zhou J, Saghayam S, Vanar S, Phanuphak N, Chen YM, Sirisanthana T, Sungkanuparph S, Lee CK, Pujari S, Li PC, Oka S, Saphonn V, Zhang F, Merati TP, Law MG, Choi JY, for TREAT Asia HIV Observational Database. Prevalence of and risk factors for lipodystrophy among HIV-infected patients receiving combined antiretroviral treatment in the Asia-Pacific region: Results from the TREAT Asia HIV Observational Database (TAHOD). Japan Endocrine Society. 2011 Apr 27. [Epub ahead of print]