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.