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The newspaper of The Johns Hopkins University November 1, 2004 | Vol. 34 No. 10
Tackling the Effects of 'Drug Cocktails'

Endocrinologist Todd Brown and HIV specialist Joseph Cofrancesco Jr. oversee one of the few clinics in the world to deal specifically with lipodystrophy.

New clinic focuses on problems unique to HIV/AIDS treatment

By David March
Johns Hopkins Medicine

Thanks to advances in treatment, HIV-infected individuals today can live longer and relatively healthier lives. But what are the physical effects of prolonged life with HIV? This once uncharted territory has begun to be mapped out.

Up to 50 percent of patients on HIV medications — so-called "drug cocktails" — experience lipodystrophy, conditions that broadly include increased rates of diabetes and pre-diabetes; development of fat inside the abdomen, or fat loss and wasting in the buttocks, face, limbs and some areas of skin; elevated blood cholesterol levels; and osteoporosis.

Now the Johns Hopkins School of Medicine has established a clinic focused on the treatment of these body fat and metabolic changes that profoundly affect people undergoing therapy for HIV and AIDS.

"As the death and hospitalization rates from AIDS have rapidly declined over the past decade, due to advanced medications, more people are living with HIV as a chronic illness. Now the long-term effects of this are becoming clear, and the problems with lipodystrophy and body metabolism can be severe," said HIV specialist Joseph Cofrancesco Jr., associate professor of medicine and director of the new clinic. "Everything to do with treating HIV disease is complicated and requires specialization. For instance, some common medicines used for treating high blood cholesterol cannot be used with other AIDS drugs."

It is not yet known if lipodystrophies are primarily long-term complications of medications needed to keep in check the body's HIV levels or are physiological effects of the virus over time. Currently, the Johns Hopkins AIDS Service cares for 3,200 patients in the region and surrounding states who are HIV-positive. The clinic is open from 1 to 5 p.m on two Mondays a month; patients can call 410-955-6414 to make an appointment.

"We wanted to harness the broad clinical resources available at Johns Hopkins to develop what we expect will be an increasingly necessary service to the community," Cofrancesco said.

He and his colleagues presented their latest research on the topic Oct. 26 at the Sixth Annual Workshop on Adverse Drug Reactions and Lipodystrophy in HIV, held in Washington, D.C.

"Treating the long-term complications from HIV disease is really like caring for a moving target," said the clinic's co-director, endocrinologist Todd Brown, assistant professor of medicine. "The medications for treating the disease are changing so rapidly and, with them, the levels of side effects. What we hope to do over time is develop a track record of identifying the most likely problems ahead of time so that we can take preventive action, including medication adjustment and dietary changes to minimize blood cholesterol problems and diabetes risk. For problems with physical appearance, as impacted by fat changes, we can also offer referrals to dermatologists and plastic surgeons."

In patients on an HIV drug cocktail — highly active anti-retroviral therapy, or HAART for short — body fat changes have been reported in 20 percent to 70 percent; insulin resistance has increased from 50 percent to 60 percent; and diabetes is developing in 10 percent to 14 percent. A January 2004 study by Brown and colleagues showed that among HIV-positive men on HAART, the incidence of diabetes was four times higher than in the general, HIV-negative male population.

Located at the Johns Hopkins Outpatient Center, the clinic is staffed by the two physicians plus a nurse and nutritionist with expertise in HIV care. Funding for the clinic is provided solely by Johns Hopkins. The new clinic is among only a few in the world to deal specifically with lipodystrophy; others exist in San Francisco; Boston; London; and Sydney, Australia.


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