HIV-associated lipodystrophy: epidemiological analysis of a Plastic Surgery Service in Brazil
Lipodistrofia associada ao HIV: análise epidemiológica de um Serviço de Cirurgia Plástica no Brasil

INTRODUCTION

In 2020 begins the fifth decade of facing the epidemic caused by the Human Immunodeficiency Virus (HIV) in the world; Brazil is one of the best-organized countries, with its policy of access to universal and integral health as a highlight, with a reduction in the lethality and increased survival¹,²,³.

In 1985, the Ministry of Health began structuring the direct fight against the disease by creating the Acquired Immunodeficiency Syndrome Control Program (AIDS)⁴. In 1991, zidovudine (AZT) was incorporated into the medicines of the Unified Health System (SUS), and in 1996, antiretroviral therapy was introduced and distributed universally and free of charge to people with HIV⁵.

With the advent and incorporation of this therapeutic arsenal, there was an increase in patient survival; however, not free of side effects and complications, such as cardio and cerebrovascular diseases, insulin resistance, and lipodystrophy⁶,⁷.

Primarily related to the class of protease inhibitors, lipodystrophy may be associated with different antiretroviral drugs and other factors, such as the inflammatory state of the infection, the phenomenon associated with immune reconstitution, and aspects of the host, such as age and sex⁸,⁹.

The prevalence of this complication varies in the literature, between 6 and 80%¹⁰,¹¹, and has different manifestations, such as lipoatrophy of the face, buttocks, and limbs, and accumulation of fat in the abdominal and cervical regions¹²,¹³.

Lipodystrophy, in addition to presenting aesthetic consequences, also involves psychosocial aspects, as it is stigmatizing and affects patients’ quality of life, which may lead to interruption and therapeutic discontinuation in some cases¹²,¹⁴.

In 2004, the Ministry of Health launched an ordinance to offer these patients access to plastic surgery to offer free treatment for HIV-related lipodystrophy. There was the inclusion in the SUS of surgical procedures, such as liposuction, gluteal implants, reduction mammoplasty, and ancillaries, such as the application of polymethylmethacrylate (PMMA)¹⁵.

The inclusion criteria were described in an ordinance of the following year, 2005. Diagnosis of HIV/AIDS and use of antiretroviral drugs for at least 12 months; patients who did not respond to switching or cannot be switched to antiretrovirals; clinically stable; CD4 greater than 200; viral load (VL) less than 10,000 copies were included¹⁵.

In our service, Department of Plastic Surgery of Faculdade de Medicina de Botucatu (FMB) – Universidade Estadual Paulista (UNESP), we are accredited to this type of service, respecting all regulations and ordinances in force.

OBJECTIVE

To evaluate the epidemiology of patients treated at the HIV-related Lipodystrophy Outpatient Clinic at the Hospital das Clínicas (HC) of the FMB and the most common treatments.

METHOD

The study was conducted retrospectively, with port analysis of patients treated at the Lipodystrophy Outpatient Clinic, between June 2012 and December 2019, at HC da UNESP in Botucatu, São Paulo, Brazil.

Data were collected in an Excel table and analyzed descriptively.

All patients undergoing invasive procedures were within the criteria established by the Ministry of Health15 and the Plastic Surgery team at HC UNESP, with a Body Mass Index (BMI) limit of less than or equal to 25 kg/m².

Patients who did not return 12 months after the last consultation were considered lost to follow-up.

All procedures performed in this study followed the 1964 Declaration of Helsinki and its subsequent amendments. The local Ethics Committee approved this study (protocol number: 38919020.6.0000.5411).

RESULTS

During the analyzed period, 172 patients received care. Of these, 19 patients were excluded from the study due to the absence of HIV-related lipodystrophy, thus leaving 153 individuals.

The mean age was 45.6 years (between 19 and 68 years). There were 79 male and 74 female patients.

Referrals came from 48 cities in four states (São Paulo, Paraná, Mato Grosso do Sul, and Ceará).

White patients totaled 116 (74.5%) attendances, 18 brown (10.4%), 10 black (5.9%), and nine without information (5.2%).

The complaint of facial lipodystrophy was reported by 81 (52.9%) patients, with a predominance of this condition in males, being the reason for seeking care in 74.3% of individuals of this gender. Despite a lower prevalence than men, 25.8% of women sought care due to facial complaints, thus constituting the most frequent complaint of females in our outpatient clinic (Table 1).

Table 1 - Main complaints of patients in consultations performed at the Lipodystrophy outpatient clinic.

In females, lipodystrophy of the abdomen (24.7%), breasts (17.9%), and buttocks (24.6%) were highly frequent.

The most common invasive procedure was facial filling with PMMA in 62 patients (50 men and 12 women).

Another 20 patients underwent surgical procedures, 27 performed in an inpatient setting and three on an outpatient basis. Including gluteal implants was the most common procedure on six occasions, followed by GIBA liposuction, with four procedures, and lipoabdominoplasty, with three (Table 2). In the queue, awaiting surgery, we counted 26 patients, but 11 had a BMI above 25 kg/m², six needed comorbidity control, such as HCV, SAH, and smoking, and two were awaiting current CD4 and viral load tests. With that, we have seven patients ready for the surgical procedure.

Table 2 - Main surgical procedures performed.

Forty-five patients lost outpatient follow-up. Of these, 11 needed weight loss, four needed better control of underlying pathologies, two were serving time in a closed regime, and they moved to another city when released. The remaining 24 contained no information.

DISCUSSION

The numbers presented in this article are unique in the literature, as we present general data from our series; thus, we included all patients with complaints of lipodystrophy without selecting patients by anatomical areas or procedures performed¹⁶,¹⁷,¹⁸,¹⁹,²⁰,²¹,²².

There is a slight predominance of males. The difference found in our sample, the M: F ratio of 1.06, differs from AIDS epidemiology data in Brazil, with a more marked prevalence and incidence in men, where this ratio is currently at 2.6²³. This can be explained by the fact that women tend to develop more lipodystrophy and complain more about the aesthetic alterations caused by antiretrovirals²².

Caucasian patients had the largest share of consultations in our outpatient clinic, 74.5%. Although, as of 2014, the prevalence of HIV-positive patients in the national territory is of the brown race, with over 40% of those infected, only 10.4% of our casuistry were brown and 5.9% black. Studies in the literature indicate greater difficulty for black and brown people to access HIV treatment, even with the universality and equity of the SUS, which could explain the low demand for these groups. The factors pointed out were socioeconomic reasons, social marginalization, structured racism, and difficulty understanding the disease and therapy²⁴,²⁵,²⁶.

Attending patients from different states indicates the difficulty of access to this specific type of care. Despite the recognized quality of HIV treatment in Brazil, there are still geographic discrepancies regarding the location and access to specialized health services for this disease, with patients requiring long journeys. This accessibility difficulty can hurt these patients’ care, leading to low adherence and discontinuity²⁷.

The main reason for seeking our Lipodystrophy Outpatient Clinic was facial atrophy, mostly in men. These data are similar to the literature, in which the male gender was also predominant in this complaint. Treatment was performed in 76.5% of them with facial filling using polymethylmethacrylate, a non-absorbable substance approved by the SUS, which brings satisfactory and safe results for patients²⁸,²⁹,³⁰,³¹,³².

The most frequently performed surgical procedure was augmentation gluteoplasty with implants, and the second in frequency was Giba liposuction. These data contrast the literature, in which Giba liposuction was the most performed procedure¹⁷,¹⁹.

Another piece of information worth mentioning is the number of patients lost to follow-up, 45 (29.4%). There is no literary reference to this data in a Plastic Surgery outpatient clinic. However, HIV carriers have known unsatisfactory adherence to antiretroviral treatment, which seems to be happening in this case³³. Most of these patients had a BMI above the limit established by the team. This value aims at greater patient safety since the surgical and complication risk is greater in individuals with high BMI³⁴.

This article has limitations, such as the study’s retrospective nature, data collection based on the analysis of medical records, and the low number of patients undergoing surgical procedures. However, with these data presented, we can analyze the structure of our care and seek to improve and optimize the resources available in health networks to treat HIV-related lipodystrophy.

CONCLUSION

The data found show a higher proportion of female patients complaining of lipodystrophy compared to general data of patients with HIV. The white race was predominant, and the main complaint of lipodystrophy was facial atrophy. Facial filling with PMMA was the most common procedure.