HIV Infection and Lipodystrophy

Lipodystrophy syndromes are rare heterogenous disorders that are classified based on fat distribution, age of onset, and etiology. The pathophysiology in this group of conditions is secondary to the loss of mature functional adipocytes due to signaling errors. Diagnosis is made clinically and should be suspected in the setting of observed adipose distribution, insulin resistance, low leptin, or hypertriglyceridemia. HIV-associated lipodystrophy (HALS) is one of the complications of HAART and is reported among 12–33% of patients with HIV in developed countries, with a higher prevalence seen in middle- and low-income countries. Potential treatments for HALS include tesamorelin, a GHRH analog; r-metHuLeptin (metreleptin), a recombinant human leptin analog; or thiazolidinediones via activation of peroxisome proliferator-activated receptor-γ (PPAR-γ) that is downregulated by HAART therapy. Randomized trials demonstrate benefits in each of these drug classes, though there are no head-to-head comparison trials. Early diagnosis of HALS is essential for prevention of its metabolic implications. Clinicians must consider the risks, benefits, and costs when deciding among the potential therapies available.