HIV mortality and morbidity have decreased dramatically since the availability of HAART,1 but as life expectancy increases new metabolic complications have emerged. One of these complications is lipodystrophy (LD), also referred to as the HIV-lipodystrophy syndrome or fat redistribution syndrome. It was first described in 19982 but no standard definition has yet been described. LD involves elements related to metabolic disorders and redistribution of body fat. The most important clinical feature is the fat loss (lipoatrophy) from the face, limbs and buttocks, sometimes with central fat accumulation on the abdomen, breasts and dorso-cervical spine. These body changes, especially those in the face, are the most frequent and distressing signs of this clinical syndrome.

Patients perceive body changes, especially facial lipoatrophy, as a stressful and disfiguring symptom of their disease.3,4 They fear that fat loss represents progression of the disease and worry that visible changes may lead to unintentional disclosure of their HIV status.5 Consequently, physical manifestations of LD affect self-esteem, self-image and self-perception, and increase feelings of stigmatization.3,6,7 This in turn may cause psychological distress and negatively affect social, professional and sexual relationships,3,5,7 leading to limited participation in physical activities, poor social functioning, loneliness and isolation.4,7,8

Psychopathology and psychosocial adjustment has been studied previously but findings are controversial. Collins et al.3 and Power et al.,7 for example, investigated quality of life and psychosocial adjustment in HIV-1 positive patients with LD and found that anxiety and depression were higher than in non-LD patients. On the other hand, Preau et al.9 found LD to be independently associated with depression but not with anxiety. However, Steel et al.10 studied the effects of LD on quality of life and depression in HIV-infected men on HAART but did not find any association between LD and depression. Much of this controversy may be due to differences in population samples and methodologies: study samples were mainly small and non-homogenous, and the methods used varied from qualitative to quantitative approaches.

Psychopathology and psychosocial adjustment in HIV infected patients with LD compared to those without LD therefore remains unclear. Furthermore, no studies have yet been performed using validated tools in the Spanish population.

The purpose of this study was to determine whether psychopathology and psychosocial adjustment in HIV-1 infected patients on HAART who developed LD differed from HIV-1 infected patients without this syndrome.

We conducted a cross-sectional study of patients receiving care at our department. The study was carried out in the Infectious Diseases Unit and the Psychosomatic Unit at the Hospital de la Santa Creu i Sant Pau, Barcelona.

All HIV positive patients on HAART receiving care at the outpatient service were invited to participate in the study. The objectives of the study were explained and patients who signed the informed consent were referred to the study psychologist. During the interview with the psychologist all inclusion and exclusion criteria were reviewed. The study was approved by the institutional ethics committee. Participants’ anonymity and confidentiality were ensured at all times.

The study population included literate female and male patients, 18 years and older, who were HIV-1 infected and on HAART. We excluded patients without the necessary Spanish language skills to answer the questionnaires and those who had any physical, psychiatric or cognitive disorders that could interfere with their participation in the study, or compromise the reliability of the self-reported measures. We also excluded patients with missing data.

Ninety per cent of patients agreed to participate in the study and signed the informed consent form. The sample consisted of 86 patients: 47 clinically evident LD and 39 non-LD patients. As there is no objective, validated, sensitive and specific case definition of HIV-associated LD,2 the LD syndrome was considered present when both physician and patient agreed that signs and symptoms of the disorder were present.11

The psychologist conducted a semi-structured interview where data related to sociodemographic factors were obtained. Psychological tests (GHQ, BDI, STAI) were self-administered and clinical variables were abstracted from medical records.

Ninety-six patients were approached and 90% (n=86) agreed to participate in the study. All participants gave written informed consent. Mean age was 42.9 (range: 24–62) years and 80.2% were men. Those with LD were on average three years older than non-LD patients (p=0.097) but differences were not significant. A total of 39.5% of the participants had completed high school, 65.1% were presently employed and 27.9% were qualified workers. More than 33% were immigrants. The percentage of immigrants was almost 20% higher in the LD group (p=0.069) but this was not statistically significant.

HIV infection was mainly transmitted by sexual intercourse and no “mode of acquisition” differences were found between groups. Patients with LD showed statistically significant higher values of viral load (p=0.037). No statistical differences were found between LD patients who were diagnosed some years earlier (p=0.068) and were on HAART regimen for a longer period (p=0.065) and non-LD patients. Sociodemographic and clinical variables are shown in Table 1.

When studying psychosocial adjustment (detailed results in Table 2), LD patients referred worse work adjustment (p=0.019) as compared to non-LD patients.

In the current study we found that HIV-1 infected patients with LD had non-significantly higher pathological scores in the psychopathology questionnaires than non-LD patients. Scores for all tests were higher in both groups than scores reported in the literature for the general population.26,27

The GHQ scores for the total sample were pathological according to the aforementioned threshold criteria. These results are in line with many findings in the literature.13,14 When we compared the differences in psychopathology in LD and non-LD groups neither the mean scores nor the percentages of positive test scores were significantly different between groups. A more specific questionnaire would perhaps reveal psychopathological traits in LD patients that are not captured by the GHQ. Interestingly, patients with positive GHQ scores showed that “being unemployed” and “maladjustment to stressful events” were predictors of pathological scores in the GHQ in the multivariate analysis. This is in agreement with previous results from Lyketsos et al.18 and Hays et al.28 who found that being unemployed was a predictor of depression in HIV-1 infected patients.

Before HAART, the prevalence of depression in HIV-1 infected patients was reported to be much higher than in the general population, as stated by Lyketsos et al.18 and Judd et al.19 After 1996, HIV disease became treatable thanks to the availability of protease inhibitors, and the prevalence of depression decreased.20 Our results support these changes as the prevalence of depression was lower than that reported by Lyketsos et al.18 and Judd et al.19 We did not find any significant difference when comparing LD and non-LD patients, as stated by others.9 Authors such as Collins et al.3 and Power et al.7 suggest a relationship between LD and depression but these studies did not use validated instruments and depression was recorded only as a symptom. In our multivariate analysis “social maladjustment” and “maladjustment to stressful events” were positive predictors of pathological BDI scores, as reported previously by de Ridder et al.29 and Fehr et al.30

More than one-third of the total sample scored above the threshold criteria on both STAI scales, with the LD group showing higher values and higher percentages of pathological results than non-LD patients. Studies using the STAI to compare HIV-1 infected patients with the general population have found higher scores in the former but none of these reviews included LD patients.24 Power et al.7 performed a study with a small number of HIV-1 infected patients with LD using a semi-structured interview and found that fat redistribution was a predisposing factor for greater anxiety. Our analysis showed that “social maladjustment” and “maladjustment to stressful events” were predictors of pathological trait anxiety scores, while “being unemployed” and “maladjustment to stressful events” were predictors of pathological state anxiety scores. In our multiple regression model LD was not a predictor of trait anxiety or state anxiety. Although LD was not the most powerful predictor of anxiety, more detailed analyses in larger samples may reveal stronger associations since the whole HIV-1 sample had higher anxiety state scores than general population.

One of the limitations of this study is that it attempts to evaluate psychological aspects of a very complex syndrome. Our sample was small and we were unable to draw conclusions for subgroups of gender, age or LD severity. It should also be mentioned that the study was conducted in the outpatient service of a 600-bed tertiary university hospital in a cosmopolitan city where stigmatization concerning HIV infection has notably decreased in recent years. The sample is therefore not a true representation of the HIV community in our country as we did not include patients from smaller towns or rural areas where HIV infection and fat redistribution would perhaps have a deeper psychological impact due to higher stigmatization. A final limitation of this study is that we did not have a control group from the general population.

In conclusion, LD causes body disfigurement and has a profoundly negative impact on the psychological wellbeing and on the psychosocial adjustment of those affected. Although we did not find statistically significant differences between the two groups we think this is likely because variables such us LD severity, self-perception, gender and age were not included in the analysis. Studies with larger samples sizes are needed to better define the relationship between this very complex syndrome and its real psychological repercussions.

The authors declare no conflict of interest.