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Open Access Research article

High prevalence of lipoatrophy in pre-pubertal South African children on antiretroviral therapy: a cross-sectional study

Steve Innes1*, Mark F Cotton1, Richard Haubrich2, Maria M Conradie3, Margaret van Niekerk4, Clair Edson5, Helena Rabie5, Sonia Jain6, Xiaoying Sun6, Ekkehard W Zöllner7, Stephen Hough3 and Sara H Browne8*

Author Affiliations

1 Department of Paediatrics, Children’s Infectious Diseases Clinical Research Unit (KID CRU), Tygerberg Children’s Hospital, Stellenbosch University, Cape Town, South Africa

2 Antiviral Research Centre, University of California, San Diego, USA

3 Department of Medicine; Division of Endocrinology, Stellenbosch University, Cape Town, South Africa

4 Department of Dietetics, Stellenbosch University, Cape Town, South Africa

5 Department of Paediatrics, Stellenbosch University, Cape Town, South Africa

6 Biostatistics Research Center, Department of Family and Preventive Medicine, University of California, San Diego, USA

7 Department of Paediatrics; Division of Endocrinology, Stellenbosch University, Cape Town, South Africa

8 Department of Medicine, Division of Infectious Diseases, University of California, San Diego, USA

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BMC Pediatrics 2012, 12:183  doi:10.1186/1471-2431-12-183

Published: 23 November 2012

Abstract

Despite changes in WHO guidelines, stavudine is still used extensively for treatment of pediatric HIV in the developing world. Lipoatrophy in sub-Saharan African children can be stigmatizing and have far-reaching consequences. The severity and extent of lipoatrophy in pre-pubertal children living in sub-Saharan Africa is unknown.

In this cross-sectional study, children who were 3-12 years old, on antiretroviral therapy and pre-pubertal were recruited from a Family HIV Clinic in South Africa. Lipoatrophy was identified and graded by consensus between two HIV pediatricians using a standardized grading scale. A professional dietician performed formal dietary assessment and anthropometric measurements of trunk and limb fat. Previous antiretroviral exposures were recorded. In a Dual-Energy X-ray Absorbtiometry (DXA) substudy body composition was determined in 42 participants.

Among 100 recruits, the prevalence of visually obvious lipoatrophy was 36% (95% CI: 27%–45%). Anthropometry and DXA measurements corroborated the clinical diagnosis of lipoatrophy: Both confirmed significant, substantial extremity fat loss in children with visually obvious lipoatrophy, when adjusted for age and sex. Adjusted odds ratio for developing lipoatrophy was 1.9 (95% CI: 1.3 - 2.9) for each additional year of accumulated exposure to standard dose stavudine. Cumulative time on standard dose stavudine was significantly associated with reductions in biceps and triceps skin-fold thickness (p=0.008).

The prevalence of visually obvious lipoatrophy in pre-pubertal South African children on antiretroviral therapy is high. The amount of stavudine that children are exposed to needs review. Resources are needed to enable low-and-middle-income countries to provide suitable pediatric-formulated alternatives to stavudine-based pediatric regimens. The standard stavudine dose for children may need to be reduced. Diagnosis of lipoatrophy at an early stage is important to allow timeous antiretroviral switching to arrest progression and avoid stigmatization. Diagnosis using visual grading requires training and experience, and DXA and comprehensive anthropometry are not commonly available. A simple objective screening tool is needed to identify early lipoatrophy in resource-limited settings where specialized skills and equipment are not available.