Fat Distribution in Women With HIV Infection

Study of Fat Redistribution and Metabolic Change in HIV Infection (FRAM)


J Acquir Immune Defic Syndr. 2006;42(5):562-571. 

In This Article

Abstract and Introduction


Objective: Both peripheral fat loss and central fat gain have been reported in women with HIV infection. We determined the fat changes that are specific to HIV infection in women.
Methods: HIV-infected and control women from the study of Fat Redistribution and Metabolic Change in HIV Infection (FRAM) were compared. Lipoatrophy or lipohypertrophy was defined as concordance between participant report of fat change and clinical examination. Whole-body magnetic resonance imaging measured regional adipose tissue volumes. The relationship among different adipose tissue depots was assessed. Factors associated with individual depots were analyzed using multivariate linear regression.
Results: HIV-infected women reported more fat loss than controls in all peripheral and most central depots. Peripheral lipoatrophy was more frequent in HIV-infected women than controls (28% vs. 4%, P < 0.001), whereas central lipohypertrophy was similar (62% vs. 63%). Among HIV-infected women, those with central lipohypertrophy were less likely to have peripheral lipoatrophy (odds ratio, 0.39; 95% confidence interval, 0.20 to 0.75, P = 0.006) than those without central lipohypertrophy. On magnetic resonance imaging, HIV-infected women with clinical peripheral lipoatrophy had less subcutaneous adipose tissue (SAT) in peripheral and central sites and less visceral adipose tissue (VAT) than HIV-infected women without peripheral lipoatrophy. Compared with controls, HIV-infected women had less SAT in the legs, regardless of the presence or absence of lipoatrophy. However, those without lipoatrophy had more VAT and upper trunk SAT than controls. Use of the antiretroviral drug stavudine was associated with less leg SAT but was not associated with VAT. The use of highly active antiretroviral therapy, however, was associated with more VAT.
Conclusions: Peripheral lipoatrophy occurs commonly in HIV-infected women but is not associated with reciprocally increased VAT or trunk fat.


Fat distribution changes, including fat loss in the face, arms, legs, and buttocks, and fat gain in the upper back, abdomen, viscera, and breast have been reported in HIV infection and are often referred to as "lipodystrophy" or "fat redistribution syndrome."[1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25] Early studies in HIV-infected women suggested that fat gain particularly in the abdomen, breast, and upper back might be the dominant change.[12,13] One study also reported that HIV-infected women had a 12% higher prevalence of fat distribution changes than HIV-infected men.[26] Understanding the changes in fat that occur in HIV-infected women is critical because these fat changes may be associated with adverse metabolic parameters that predict increased risk of cardiovascular disease.

The lack of consensus defining fat changes in HIV has made research into etiology difficult and led to dilemmas among health care providers as to how to counsel patients regarding fat changes. Most published reports assessed fat changes using a participant's report of change, confirmed on examination by a health care provider.[2,4,6,10,11,12,13,15,20,25,27,28,29,30] Studies have also used different definitions to define fat changes in HIV. Some defined fat changes as occurring in either peripheral or central body sites,[2,3,4,10,16,25,31] some combined both peripheral and central fat changes into 1 syndrome,[11,12,13,18,20,22,27,28] and others reported separately on lipoatrophy only, lipohypertrophy only, and "combined" syndromes.[15,17,21,23,24,29,30] Most studies used unidirectional questionnaires that presumed the presence of anticipated findings of peripheral lipoatrophy and central lipohypertrophy.[6,11,12,15,17,21,23,24,27,28,29,30,32] Thus, there remains a debate about the definition of the syndrome.[1,15,17,20,24,29,30,32,33,34]

Early studies also did not include an HIV-uninfected comparison group. A more recent longitudinal study from the Women's Interagency HIV Study (WIHS) cohort found that lipoatrophy (defined as participant's report of body fat loss confirmed by anthropometry) distinguished HIV-infected women from uninfected women.[35] In a cross-sectional subset of women from the WIHS, direct measurement of leg and trunk fat using dual x-ray absorptiometry scans demonstrated an inverse association between duration of stavudine use and leg fat.[36]

The interrelationships among the changes in fat distribution must be defined before prevalence, etiologic factors, and associated metabolic changes can be studied. Therefore, in the study of Fat Redistribution and Metabolic Changes in HIV Infection (FRAM), we evaluated self-reported changes in fat in the context of physical examination by trained observers using bidirectional instruments, and magnetic resonance imaging (MRI) measured regional subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) volume in HIV-infected and control men and women using the same protocol. We report here our findings in HIV-infected and control women comparing fat distribution as assessed by self-report, physical examination, and MRI. Among the HIV-infected women, we also present our findings on the interrelationships of fat distribution across peripheral and central body regions, and their associations with antiretroviral therapy. Our findings in HIV-infected and control men have previously been reported.[37]


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