Whilst watching a recent historical film, we were struck by the facial appearance of the actor portraying the evil character. A diagnosis of HIV-associated lipodystrophy seemed probable. By coincidence, we too have an actor patient who, prior to intervention, found himself repeatedly cast in the role of the sinister, untrustworthy bad guy. Why we wonder? Are patients with facial disfigurement evil? Or do we as a society hold deeply entrenched prejudices?
As surgeons, we find ourselves grappling with many of the issues surrounding HIV and our duty of care to the patient. Since human immunodeficiency virus (HIV) infection was first recognised in 1981, it is estimated that about 0.6% of the world's population has become infected.1 HIV is a lentivirus, a subgroup of retroviruses, which has high affinity for CD4+ T lymphocytes and monocytes. After binding to CD4+ T cells and becoming internalized, the virus replicates itself by generating a DNA copy by reverse transcriptase. Viral DNA then becomes incorporated into the host DNA, enabling further replication. Infection with HIV-1 is associated with a progressive decrease of the CD4+ T cell count and an increase in viral load. The initial infection with HIV generally occurs after transfer of body fluids from an infected person to an uninfected one. The first stage of infection is a period of rapid viral replication, accompanied by a marked drop in the numbers of circulating CD4+ T cells, and subsequently with antibody production, or seroconversion. Most individuals develop an influenza-like illness in the acute phase, followed by a stage of clinical latency, which varies between two weeks and 20 years. The stage of infection can be determined by measuring the patient's CD4+ T cell count, and the level of HIV in the blood. When CD4+ T cell numbers decline below a critical level, cell-mediated immunity is lost, and the body becomes progressively more susceptible to opportunistic infections. The CDC (Centres for Disease Control and Prevention) classification2 is the currently accepted method of staging HIV disease, and is based on three ranges of CD4+T-lymphocyte counts and three clinical categories (summarised in Table 1, Table 2). If untreated, eventually most HIV-infected individuals develop AIDS (Acquired Immunodeficiency Syndrome) and die; however about one in ten remains healthy for many years, with no noticeable symptoms.3
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 | Category | Clinical manifestation | |
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| A | Consists of one or more of the following conditions: •Asymptomatic HIV infection •Persistent generalized lymphadenopathy •Acute (primary) HIV infection with accompanying illness or history of acute HIV infection | |
| B | Occurrence of symptomatic conditions in an HIV-infected adult including: candidiasis, cervical dysplasia, hairy leukoplakia, herpes zoster (shingles), and peripheral neuropathy. | |
| C | Occurrence of a clinical condition listed in the AIDS surveillance case definition including: cytomegalovirus disease, Kaposi's sarcoma, Pneumocystis carinii pneumonia, toxoplasmosis of brain. | |
| | |
Since the introduction of highly active antiretroviral therapy (HAART), life expectancy from HIV infection has significantly improved. However, side effects from these drugs including HIV-associated lipodystrophy,4 coronary heart disease5 and avascular necrosis6 have increased demands for surgical interventions in HIV-infected patients, particularly in the fields of plastic, cardio-thoracic and orthopaedic surgery. HIV-associated lipodystrophy is now a well-recognised syndrome, first described by Carr in 1998. It is strongly associated with antiretroviral therapy although the underlying pathogenesis remains unclear. Despite concurrent fat alterations to the trunk and limbs, facial lipoatrophy remains the most common presentation to plastic surgeons and the most distressing clinical feature for patients. Before considering the issues specific to HIV lipodystrophy and facial disfigurement, the plastic surgeon should be aware of the current situation with regards to surgery in HIV-infected individuals.
Negative attitudes towards operating on HIV patients from the medical profession remain, despite improvements in surgical morbidity and mortality over the years. Surgeons may be reluctant to treat HIV patients for several reasons: (1) fear of contracting HIV infection; (2) perceived problems of wound healing, infection and co-morbidity; (3) judgemental attitudes towards patients' lifestyle choices. A somewhat nihilistic attitude towards operating on HIV-positive patients developed as a consequence of early results of emergency surgery in AIDS patients. Complication rates up to 140%7 and mortality rates ranging between 55–70% were reported.8, 9 There is now increasing evidence that strongly contradicts the early experience of surgery in these patients.10, 11, 12, 13 The disappointing early results of surgery in patients with HIV disease are now believed to have resulted from the fact that many patients were in the terminal stages of the disease, combined with a poor understanding of the disease and the timing of surgery. The risk of elective surgical procedures in patients with blood-borne diseases has improved significantly. Postoperative morbidity and mortality are related to the stage of the blood-borne disease, whether the operation is being performed as a complication of the primary disease, and the functional status of the patient. A review of HIV patients with an early stage of disease undergoing elective procedures for conditions not related to HIV disease has revealed similar surgical risks for patients without HIV infection.14
Assessment of the patient's pre-operative physiological status (including an assessment of nutritional reserve) is considered to be the best predictor of surgical morbidity and mortality.14
Several authors have identified predictors of poor prognosis in patients with AIDS including: (1) active opportunistic infection,7, 12, 13 (2) a serum albumin less than 2.5
g/dL7, 10 and the presence of concurrent organ failure.8 These risks are similar for any immunocompromised, malnourished patient.
To ensure optimal safety for both the patient and the operating team, it is recommended that the HIV-1 RNA viral load should be maximally suppressed at the time of surgery (HIV-1 RNA <50copies/mL).15, 16 Recommendations on preoperative CD4+ count are lacking, although a CD4+ count less than 200cells/mm3 is considered suboptimal for elective procedures by some surgeons.
In addition to considering the surgical risk for HIV patients, a major concern for the surgeon is the risk of sharp injury and the potential consequences of this. Percutaneous injury may occur in as many as 15% of operations,17 although the frequency of needle-stick injuries is decreasing.18 The mean risk of acquiring HIV infection after a percutaneous exposure is 0.3%. Although the virus may be transmitted after exposure to the mucous membranes and non-intact skin, the risk is probably less than parenteral exposure. Factors surrounding a needlestick exposure can either increase or decrease the risk of transmission. Large volume exposures, such as those involving large-bore, hollow needles, intramuscular penetration, or actual injections of HIV-infected blood increase the transmission risk. Seroconversion rates of 15% to 30% have been observed with hollow needle injuries, especially if there is deep penetration of the injured person's tissues. A source patient with a high plasma viral load may be the single most important predictor of transmission. The viral titre of infected fluid may vary up to 10000-fold depending on the clinical stage of the patient's disease.19
Generally the procedures carried out for patients with HIV-associated lipodsytrophy (autologous fat transfer, fillers, liposuction) are associated with relatively low risk to both the patient and surgeon (Fig. 1). Barrier protective measures employed for treating HIV-infected patients in our unit include disposable aprons, impermeable gowns, masks, eye protection, head and foot protection and double gloves. We also operate using a ‘no-touch’ method of instrument passage which is associated with a reduced injury rate.20 Despite this, there have been three incidences of sharps injury in this unit during the treatment of patients with HIV-associated lipodystrophy. One incident occurred during a short scar facelift procedure, and another incident occurred during a full facelift procedure. Both procedures were performed for skin laxity secondary to loss of facial volume as a consequence of lipodystrophy. The causal agent was a skin hook, which slipped and caught the surgeon's hand. We now no longer use skin hooks in this procedure, preferring to clip the skin which is destined for excision. The third incident occurred during injection of Newfill®. All three members of staff required post-exposure prophylaxis (PEP) for one month, with the associated anxiety over seroconversion, which thankfully did not occur. Some studies have demonstrated efficacy of post-exposure prophylaxis in animal models and in reducing mother-to-infant HIV transmission.21 Little information exists from which the efficacy of PEP in humans can be assessed as seroconversion is infrequent following an occupational exposure to HIV-infected blood. A randomized controlled trial would require a large sample size and would be neither ethical nor practical. A recent review concludes that healthcare workers should be counselled that PEP is not 100% effective in preventing HIV seroconversion.22 The side effects of prophylactic anti-retroviral therapy can also be fairly unpleasant and include nausea and gastrointestinal cramps. Obviously, the impact of contracting HIV infection for a surgeon has huge implications for career, family life and general health, and may be a risk that some are not willing to contemplate.
Taking these risks into account, treating patients with HIV-associated lipodystrophy can be a rewarding experience. The disfiguring effects of lipodystrophy can be difficult for patients to accept, resulting in tremendous psychological morbidity. Social isolation may occur as a consequence of embarrassment or self-consciousness over change in facial appearance. More importantly, however, is the stigmatising nature of the condition. Given the sensitive and confidential nature of HIV, the condition is a cruel disclosure of the patient's HIV status. Recognition of the condition as a consequence of treatment with anti-retroviral therapy, particularly amongst ‘at risk’ groups is increasing. As a consequence, whether real or imagined, patients often feel judged or discriminated against. Amongst the ‘at risk’ groups, MSM (Men who have sex with men) continue to be disproportionately affected by HIV and account for 63% of new diagnoses in the past year.23 Interestingly, this group accounts for the majority of the referrals to our unit seeking treatment for HIV-associated lipodystrophy.
HIV-associated lipodsytrophy can affect many aspects of patients' lives including relationships, work and family. The condition is also a permanent reminder to patients of their HIV status. Severe fat wasting in some patients results in an emaciated appearance, making them appear unwell despite good HIV control.
The physical and psychological effects of HIV-associated lipodystrophy form the basis of a strong case, within the context a socialised healthcare system, for public funding of treatment. However, there are some who might consider treatment for lipodystrophy to be primarily cosmetic in nature and therefore not justifiable at public or insurer expense. Indeed, this has been a difficult political issue for physicians throughout the UK. Developing a case for such funding is a time-consuming and often frustrating process. The cost of treatment is the fundamental consideration. Those patients with inadequate fat reserves to facilitate fat transfer require fillers, which are expensive. The choice of filler also poses a clinical dilemma for the physician. In our review of the literature, we discovered a paucity of objective evidence comparing products in the treatment of lipodystrophy to date.24 Studies have demonstrated clinical effectiveness of autologous fat, Newfill® (Poly-L-lactic acid) and Bio-alcamid® in the treatment of HIV-associated lipodystrophy. By our estimation, taking into account product, staff, consumable and revisions, the cost of all three treatments are broadly comparable.
We have recently assessed patient satisfaction following various treatments for HIV-associated lipodystrophy,25 which uncovered some more unforeseen issues. Whilst the majority of patients are satisfied with the cosmetic result and are extremely grateful for any treatment received, there are some patients who become increasingly demanding. Despite correction of lipoatrophy, the primary aim of treatment, some patients can become overly concerned with their facial appearance, placing undue emphasis on minor asymmetries. Some may also request cosmetic procedures to other areas of the face. Whilst in many cases this would undoubtedly improve their cosmetic appearance, these changes are not due to lipoatrophy. The question of where one draws the line is raised.
The surgical treatment of patients with HIV has always raised moral issues. The issue of offering cosmetic treatments to these patients may be considered by some to be an unnecessary risk to staff and waste of public resource. Patients with HIV-associated lipodystrophy may then be required to seek treatment from other sources. Physicians of all specialties are becoming trained in cosmetic surgery and offering cosmetic services as part of their office practice. Increasingly such services are being offered by unsupervised, non-medical staff. The debate over who should be offering these services raises many controversial issues and is perhaps a separate topic in its own right. However, the argument has relevance to patients with HIV-associated lipodystrophy who have become increasingly desperate for treatment. The manufacturers of Bio-alcamid® have limited its use to qualified medical professionals. One may argue, however, that physicians administering Bio-alcamid® should also possess surgical skills. The procedure itself may require extensive needle dissection of large subcutaneous pockets, perhaps more suited to the skills of a surgeon. Moreover, the reported long-term complications including infection, migration and capsular contraction may all require open surgical correction.26 Courses to demonstrate the technique have been attended by clinicians with cosmetic interests, including general practitioners and dentists. But should physicians be administering treatments with potential complications out with their clinical abilities? With the increasing use of these products, plastic surgeons may find themselves dealing with the long-term complications.
Offering a service to treat patients with HIV lipodystrophy can be an extremely rewarding experience. Although incidence of HIV lipodystrophy may be declining as a result of newer antiretroviral drugs, plastic surgeons will undoubtedly be confronted with these patients due to increased public awareness of available treatments. We would contend that the plastic surgery community has a duty of care to this patient group. What medical, moral or ethical justification can there be for offering or funding reconstruction of the iatrogenic deformity of breast cancer patients whilst denying the same right to those with HIV infection? We would also contend that plastic surgeons should take the initiative to overcome any bureaucratic hurdles to insure that care of the highest possible standard is provided to this patient group.
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