Epidemiology, Assessment, and Management of Excess Abdominal Fat in Persons with HIV Infection

Metabolic and morphologic abnormalities in persons with HIV remain common contributors to stigmaand morbidity. Increased abdominal circumference and visceral adiposity were first recognized in thelate 1990s, soon after the advent of effective combination antiretroviral therapy. Visceral adiposity iscommonly associated with metabolic abnormalities including low HDL-cholesterol, raised triglycerides,insulin resistance, and hypertension, a constellation of risk factors for cardiovascular disease anddiabetes mellitus known as “the metabolic syndromeâ€?. Medline and conference abstracts were searchedto identify clinical research on factors associated with visceral adiposity and randomized studies ofmanagement approaches. Data were critically reviewed by physicians familiar with the field. A rangeof host and lifestyle factors as well as antiretroviral drug choice were associated with increasedvisceral adiposity. Management approaches included treatment switching and metformin, both of whichhave shown benefit for insulin-resistant individuals with isolated fat accumulation. Testosterone supplementsmay also have benefits in a subset of individuals. Supra-physiological doses of recombinant humangrowth hormone and the growth hormone releasing hormone analog tesamorelin both significantlyand selectively reduce visceral fat over 12-24 weeks; however, the benefits are only maintained if dosingis continued. In summary, the prevention and management of visceral adiposity remains a substantialchallenge in clinical practice.