H.I.V. Drugs Not at Fault for Causing Gain in Girth
By DAVID TULLER
Published: November 1, 2005
SAN FRANCISCO, Oct. 31 - The new class of drugs called protease inhibitors
revolutionized the care of H.I.V. patients in 1996.

But many people who took the drugs began to lose fat tissue in their cheeks,
arms, legs and buttocks. Many also developed a paunch - nicknamed "Crix
belly" after Crixivan, one protease inhibitor - and they gained weight in
their upper trunks.
The weight loss and weight gain, known respectively as peripheral
lipoatrophy and central lipohypertrophy, were generally treated as a single
phenomenon involving the redistribution of body fat.

Some patients refused the new drugs because they worried that this syndrome,
called lipodystrophy, would mark them as having H.I.V. or AIDS.

But growing a big belly is not part of any such syndrome, according to a new
study of H.I.V.-infected men. The study, published recently in The Journal
of Acquired Immune Deficiency Syndrome, found that any weight gain in people
who took the drugs was associated with age, not with H.I.V. or protease
inhibitors.

In contrast, the study also determined that peripheral fat loss was a
distinct phenomenon and was associated with two medications that are no
longer among the first drugs prescribed for H.I.V. patients.

Dr. Mitchell Katz, director of the San Francisco Department of Public
Health, said the findings would help persuade nervous patients to start or
maintain H.I.V. treatment.
"I still have a lot of patients who are reluctant to take antiretroviral
drugs for fear they will be disfigured by lipodystrophy," Dr. Katz said. "I
think this study offers quite a lot of reassurance to them.

"It's saying that the drugs most implicated in weight loss are two that are
on their way out."

The study compared fat distribution in various parts of the body - as
measured by patient's own reporting, clinical assessment and M.R.I.
scanning - in 425 H.I.V.-infected men and in 152 uninfected men from age 33
to 45.

Of the men who were H.I.V.-positive, 38 percent suffered from peripheral
lipoatrophy, compared with 5 percent of the people in the control group.

The drugs associated with the weight loss were indinavir, the generic name
for Crixivan, and stavudine, also known as d4T, an earlier H.I.V. drug.

In addition, only 40 percent of the participants infected with H.I.V.
experienced significant weight gain around the trunk, compared with 56
percent of the control group.

And H.I.V.-positive men who had weight loss in their extremities were more
likely to have lost weight in their stomachs and elsewhere than they were to
have gained it.
Dr. Carl Grunfeld, the study's principal investigator and a professor of
medicine at the University of California, San Francisco, said the abdominal
weight gain seen in many H.I.V. patients receiving treatment was probably
related to improved health as well as aging.

He acknowledged that the paunch could appear abnormal but said it was
because of the weight loss in the extremities.

"It doesn't look like normal obesity because of the lipoatrophy," he said.
"You don't usually see people with thin arms and legs and big bellies."

Dr. Katz, the San Francisco public health director, cautioned that people
taking H.I.V. medications still could be troubled with genuine
lipohypertrophy, even though the research suggested that the drugs were not
a discernible factor within a larger population.

"The study doesn't change the fact that we can point to a few extreme
cases," he said. "But it shows we understood lipodystrophy based on that
extreme response."
Still, he said, there are also many H.I.V.-negative men "running around with
tremendous pot-bellies."

In the study, the subjects and the members of the control group were men
whose primary H.I.V. exposure was from having sex with other men.

Therefore, the findings do not necessarily reflect the experience of other
H.I.V.-infected demographic groups, like women and intravenous drug users.