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Abdominal Adiposity Not Waning With Newer Antiretrovirals in France
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12th European AIDS Conference, November 11-13, 2009, Cologne, Germany
Mark Mascolini
Abdominal adiposity--a marker of insulin resistance and rising cardiovascular risk--remained as prevalent in French men starting antiretroviral therapy after December 31, 2004 as in those who started before, according to results of a large cross-sectional study [1]. Among women, waist size grew from the earlier to the later period. Francois Raffi (University Hospital Nantes) noted that the analysis has several limitations, but he believes the findings show that belly fat buildups are continuing with antiretroviral regimens that saw wide use after 2004.
The evolution of central fat gains in the era of combination antiretroviral therapy--and even their meaning--remain incompletely understood. The US FRAM study established that central adiposity is actually less common in HIV-infected US residents than in the general population [2]. But excess central fat clearly has an ominous prognosis in men and women for numerous reasons.
Raffi's study involved 838 HIV-infected people cared for in Nantes and Marseilles, 723 of whom started antiretroviral therapy before 2005 and 115 of whom started on January 1, 2005 or later. The investigators compared these groups for abdominal adiposity, which they defined by two standards: waist circumference over 102 cm (40.2 inches) in men or over 88 cm (34.7 inches) in women, or over 94 cm (37 inches) in men and over 80 cm (31.5 inches) in women.
People in the early-treatment era had taken antiretrovirals for a median of 11.6 years, much longer than the median of 2.1 years in the newer era. Substantially more people in the newer era were taking a nonnucleoside plus two nucleosides (39.2% versus 22.5%), and substantially fewer in the newer era were taking a nucleoside-only regimen (1.7% versus 11.2%). Proportions taking a protease inhibitor regimen were 42.7% in the newer era and 48.7% in the older era. Median CD4 count stood at 523 in the older era and 472 in the newer era; 84% in both eras had a viral load below 40 copies.
For men, waist circumference did not differ significantly by antiretroviral treatment era according to either of the waist width standards used:
· Men in older era (n = 510): 29.2% >/= 94 cm
· Men in newer era (n = 85): 37.6% >/= 94 cm (P = 0.118 vs older era)
· Men in older era: 12.7% >/= 102 cm
· Men in newer era: 11.8% >/= 102 cm (P = 0.801 vs older era)
Women in the newer treatment era had significantly wider waists than women in the older era:
· Women in older era (n = 213): 52.6% >/= 80 cm
· Women in newer era (n = 30): 76.7% >/= 80 cm (P = 0.013 vs older era)
· Women in older era: 24.4% >/= 88 cm
· Women in newer era: 43.3% >/= 88 cm (P = 0.028 vs older era)
Raffi pointed out several limitations to this analysis. First, there was no statistical adjustment for factors that may influence waist size, including age, ethnicity, other illnesses, or duration of antiretroviral therapy. He noted that France has more nonwhite HIV-infected people since 2005. Second, the analysis involved only the 40% of antiretroviral-treated people in these clinics who had their waist measured, so selection bias could distort the results. (In other words, clinicians may have tended to measure waist size in certain patient groups, so the findings would not accurately reflect a complete group of antiretroviral-treated people.) Also, the investigators did not have pretreatment waist widths for these people, but only a single measure at one point during treatment. Finally, the investigators did not have data on waist size of HIV-negative people in Nantes or Marseilles, or throughout France.
Still, the study suggests that wider use of nonnucleosides since 2005 and (probably) waning use of fat-toxic nucleosides like stavudine and zidovudine have not limited excess belly fat as a problem in HIV-infected people. Indeed, in Nantes and Marseilles, the problem may be getting more common in women with HIV.
References
1. Poizot-Martin I, Obry-Roguet V, Biron C, et al. Abdominal adiposity remains highly prevalent in French HIV-infected patients having initiated antiretroviral therapy after 2005. 12th European AIDS Conference. November 11-13, 2009. Cologne, Germany. Abstract PS11/1.
2. Bacchetti P, Gripshover B, Grunfeld C, et al, Study of Fat Redistribution and Metabolic Change in HIV Infection (FRAM). Fat distribution in men with HIV infection. J Acquir Immune Defic Syndr. 2005;40:121-131.
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