The impact of experiencing lipodystrophy on the sexual behaviour and well-being among HIV-infected homosexual men

Abstract

Of 117 HIV-infected homosexual recipients of highly active antiretroviral therapy (HAART), 50.4% reported lipodystrophy. Experiencing lipodystrophy had a strong impact on the perceived health and confidence in relationships of these men. An additional decrease in the enjoyment of sex and sexual activity was noted, although this may also be the result of other aspects of HAART use. The findings underline the importance that HIV-infected individuals, who are considering starting HAART, are informed about the possibility of such effects. Clinicians should be aware of the potential impact of HAART on their patients in case side-effects develop. The use of HAART has been associated with changing views about high-risk sex [1,2]. In a previous study among homosexual men, not short-time HAART use (< 1 year) in itself, but the first HAART-induced virological and immunological improvements were likely to be associated with the (temporary) increased practice of risk behaviour [3]. Just as is observed for these specific favourable consequences of HAART, experiencing side-effects may also influence sexual behaviour in some way. Increasing attention is paid to lipodystrophy, a syndrome marked by the redistribution of body fat, and mostly attributed to the use of protease inhibitors (PI) [4–7]. Because this syndrome is associated with involuntary changes in body composition, we hypothesized that this may have a substantial influence on an individual's well-being and behaviour. We sent a questionnaire to the HIV-positive homosexual men (n = 176) who participated in the Amsterdam Cohort Studies, and were now being seen by practitioners and clinicians in Amsterdam. The response rate was high: 141 men (80.1%) completed and returned the questionnaire. Of these, 117 (83.0%) received HAART, including PI for all individual but one. Of the 117 men, who were 42.3 years of age on average [standard deviation (SD) = 8.8], 40.9% (n = 38) had a college degree, and 89.7% (n = 105) were of northern or central European nationality. Information on the duration of HIV infection was available for 38 men, who were infected for on average 8.8 years (SD = 4.6). Information on the date of starting HAART was available for 99 men, who started HAART on average 2.8 years ago (SD = 0.6). We asked the men ‘Have you ever experienced a change in fat distribution after initiating HAART (meaning: extremities getting thinner and abdominal size increasing, in medical terms called lipodystrophy)', and 50.4% (n = 59) reported lipodystrophy. In concordance with previous studies [4–7], men who reported lipodystrophy were older (mean age 45.4 years; SD = 8.3), had been HIV infected for a longer period (mean 10.6 years; SD = 4.1), and had started HAART earlier (on average 2.9 years ago; SD = 0.5) than men not reporting lipodystrophy, who on average aged 39.1 years (SD = 8.3), were HIV infected for 5.6 years (SD = 3.6), and had started HAART 2.7 years (SD = 0.6) ago. Whether or not information on the duration of infection or time since starting HAART was available was not related to reporting lipodystrophy, and neither was the level of education or nationality. We asked the 59 men who reported lipodystrophy to compare the period of experiencing this syndrome with the period before. Comparisons were made regarding sexual behaviour and well-being (Table 1), using a five-point scale (1: much less; 2: less; 3: similar; 4: more; 5: much more). A t-test was used to determine whether the mean scores differed from the neutral score (score 3, indicating no change). The 59 men who experienced lipodystrophy reported a drastic decrease in sexual activity (Table 1). Importantly, they less enjoyed sex less, felt less physically well and were less confident in relationships when experiencing lipodystrophy. In analyses of variance, answers were not influenced by sociodemographic characteristics, time of being HIV positive or time since initiating HAART (all P values > 0.05).Table 1: Mean score on nine different items for which HIV-infected homosexual men who had ever experienced lipodystrophy as a result of highly active antiretroviral therapy (n = 59) were asked to compare the period in which they had experienced lipodystrophy with the period before, Amsterdam Cohort Study 2000. This cross-sectional study was somewhat limited by the way in which variables were measured. Lipodystrophy was self-reported, which may have led to an under- or overestimation of the prevalence of ‘clinical` lipodystrophy. Although some investigators used objective 'metabolic’ criteria to define lipodystrophy, most other studies have also based their findings on subjective judgement of the syndrome [4–7]. Furthermore, individuals were asked to recall events afterwards. Recall bias might be introduced depending on the duration and severity of lipodystrophy, as well as the presence of this syndrome at the time of measurement. To what extent recall bias influenced our results, however, is unknown. In discussing the specific impact of experiencing lipodystrophy, one should also take into account changes that occurred as a result of the use of HAART per se. Therefore, we also asked men to compare the entire period of using HAART with the period before (in which they knew they were HIV positive) (data not shown). Over the entire HAART period, no change was reported in self-perceived health and confidence in relationships, contrasting with the strong decrease over the period of experiencing lipodystrophy. Therefore, lipodystrophy has probably a substantial and specific impact on a person's well-being, which can not be attributed to the use of HAART in general. Men who ever experienced lipodystrophy reported a decrease in sexual activity and the enjoyment of sex over the entire HAART period, just as over the specific period of experiencing this syndrome. This may indicate that lipodystrophy has a very strong impact on these changes, because these changes are still reflected when asked over the entire period of HAART use. On the other hand, a decrease in sexual activity in the period of using HAART was also reported by men who never experienced lipodystrophy, indicating a role of other HAART-related factors, such as the possible sexual dysfunction associated with PI use [8,9]. Over the period of experiencing lipodystrophy no change was reported in condom use, indicating that a direct impact of lipodystrophy on condom use is not likely. However, men who experienced lipodystrophy did increase their condom use when asked over the entire HAART period (whereas men not reporting lipodystrophy did not). This finding probably results from other HAART-related differences between the two groups, although differences in the time since starting HAART or age appeared not to play a role. In conclusion, a large proportion of HAART recipients experienced lipodystrophy, which probably had a strong impact on the perceived health and confidence in relationships of these men. An additional decrease in enjoying sex and sexual activity has been noted, although we cannot determine whether this is caused by lipodystrophy, other aspects of HAART, or both. The findings underline the importance of fully informing HIV-infected individuals who are considering starting HAART about the possibility of side-effects. For clinicians, this study indicates how their patients may react to HAART or HAART-related side-effects, in particular lipodystrophy, and prepares them to assist their patients in coping with such effects. Nicole H. T. M. Dukersa Ineke G. Stoltea Nel Albrechta Roel A. Coutinhoab John B. F. de Witac