Impact of switching from human immunodeficiency virus type 1 protease inhibitors to Efavirenz in successfully treated adults with lipodystrophy

Abstract

We prospectively followed 20 consecutive patients with human immunodeficiency virus type 1 (HIV-1) with viral loads of <200 RNA copies/mL. These patients had been treated with 2 nucleoside reverse transcriptase inhibitors and ≥1 HIV-1 protease inhibitor for ≥3 months; they developed body changes consistent with lipodystrophy and requested they be switched from protease inhibitor to efavirenz. At baseline and every 3 months, we assessed the following: body mass index, waist-to-hip ratio, regional fat thickness (assessed by sonography), fasting total and high-density lipoprotein cholesterol, triglycerides, glucose, insulin, CD4+ cells, and viral load. At baseline, hypertriglyceridemia (≥200 mg/dL) was present in 17 (85%) patients, hypercholesterolemia (≥200 mg/dL) in 14 (70%), and impaired fasting glucose (≥110 mg/dL) in 8 (40%); CD4+ T cells were 280 × 106 cells/L (range, 64-942 × 106 cells/L). HIV-1 RNA had been at <200 copies/mL for a median of 14 months (range, 3-24 months). Six months after switching to efavirenz, there was a reduction in triglyceride levels (a decrease of 31%; P = .03) and fasting insulin resistance index (a decrease of 28%; P = .03), but total and high-density lipoprotein cholesterol and glucose did not change. Waist-to-hip ratio decreased from 0.92 to 0.87 (P = .06). Subcutaneous fat thickness did not change. CD4+ cells remained stable (363 × 106 cells/L; range, 102-741 × 106 cells/L; P = .65). Nineteen patients (95%) had HIV-1 RNA levels that remained at <200 copies/mL. Although CD4+ response and viral suppression remained preserved after 6 months of switching from protease inhibitor to efavirenz, the benefits of this approach on the evolution of lipodystrophy were limited, and our findings do not support its routine recommendation to treat lipodystrophy.