Body fat loss study more proof of why d4T must go

HIV activists, scientists and civil society should agitate for the speedy phasing out of d4T (stavudine), despite the steep price tag of its substitution, a new study suggests.
Stavudine is one of three drugs taken in South Africa’s for people starting ARV treatment (in other words, the first line regimen).
In a clinical review of lipoatrophy and other body fat changes on d4T-based regimens, Carole Leach-Lemens found “studies support the direct link between stavudine (d4T) and to a lesser extent zidovudine (AZT) and lipoatrophy”.
Other key points include:
• Lipoatrophy is a clinical diagnosis for (under the skin) fat loss when all other explanations have been ruled out making early diagnosis very difficult
• Early detection strategies are needed since changes in body shape are difficult to reverse
• Lipoatrophy is not life-threatening but the changes in appearance are psychologically damaging and stigmatising undermining adherence
• Most first-line regimens in resource-poor settings include either stavudine or zidovudine despite recent WHO recommendations to phase out stavudine. WHO recommends a reduced dose of stavudine when phasing out is not possible
• The substitution of stavudine with either tenofovir or abacavir has shown improvements in the form of weight gain and lipoatrophy scores
“All the available data suggest that patients receiving stavudine-based ART are at high risk of developing lipoatrophy and other body fat changes, and that risk rises as time on treatment lengthens,” Leach-Lemens reported in the NAM publication, HATIP (HIV & AIDS Treatment in Practice).
“While peripheral neuropathy (pain and tingling in the hands, arm, feet and legs) is difficult to ignore when it is causing crippling pain, many people with HIV do seem to live with lipoatrophy without complaint to their health care providers, accepting it as the price that must be paid for lifegiving treatment,” she found.
“Yet there is good evidence that eventually the stigmatising effect of lipoatrophy undermines treatment adherence, and has a profound effect on quality of life.”
Leach-Lemens concluded: “In the case of first-line treatment, change will not be cheap, but the long-term cost of doing nothing will be to consign a very large number of people to years of treatment with drugs that are not just sub-optimal, but downright harmful.”