Soft tissue augmentation for HIV patients with lipodystrophy syndrome

PICHON-RIVIERE A,; AUGUSTOVSKI, F; ALCARAZ A; BARDACH, ARIEL; COLANTONIO, LISANDRO; FERRANTE, D; GARCIA MARTÍ, SEBASTIAN; GLUJOVSKY, D; LOPEZ, A; REGUEIRO, A

Documentos de Evaluación de Tecnologías Sanitarias

IECS

Año: 2006 p. 1 - 30

1668-2793

This report aims to to assess the existing evidence on the different types of treatment for HIV patients with lipodystrophy syndrome.A bibliographic search was carried out on the main data bases (MEDLINE, Cochrane, DARE, NHS EED), on general Internet engines, in health technology evaluation agencies and health sponsors. Priority was given to including systematic reviews, randomized controlled clinical trials, health technology assessments and financial assessments, clinical practice guidelines and coverage policies from other health systems. Information from local sources on the use of sanitary resources, costs and coverage in Argentina were also searched.Temporal augmentation treatments; Zyplast collagen: Bad results have been reported in a non-controlled trial which included 100 patients due to the short duration of its effect, the fact that the skin did not feel "natural" and the excessive cost because of the number of great volume injections needed.Micronized Alloderm: It was evaluated in a non-controlled trial including 25 patients. Although it presented very few adverse effects, its high cost and the need of repetitive treatments of great volume, limit its use for this indication.Particulate Fascia Lata: Injections with particulate fascia lata have not demonstrated to be effective, achieving less than a 25% correction of lipodystrophy.Autologous fat implants: It was assessed in two small non-controlled trials. Even though an improvement in facial lipoatrophy of up to 50% was observed, in general HIV patients lack donor areas of fat to perform the procedure. Also implants lasted less than 12 months.Polylactic acid: It was assessed in 6 non-controlled studies which included 472 patients with a follow-up of up to 18 months All the studies showed an increase in dermal thickness and an improvement in the patient's look. Patients were satisfied, had a better quality of life and lower levels of anxiety.Hyaluronic acid: There is poor evidence of its usefulness coming from two non-controlled trials performed in less than 10 patients with a follow-up between 6 and 12 months. In general it requires great volumes, multiple touch ups and its long term effect has not been established.Calcium hydroxylapatite: Although it has been used for long in the correction of wrinkles caused by aging, the evidence of its use in HIV patients with lipodystrophy is poor. A non-controlled study which included only 3 patients with a follow-up of up to 9 months was found. It showed an improvement between 75 and 90%.Permanent augmentation treatments; Injectable silicone fluid: A non-controlled study which included 77 patients with good results was published. The amount of silicone required, the number of treatments and the time necessary to achieve results was in direct relation to the severity of the lipodystrophy. Though it may become a cost-effective option in the future, a longer term follow-up is required. At present, a trial which included 800 patients with lipodystrophy with HIV is being carried out. Implants: In general results are incomplete and several silicone injections or some other type of augmentation are required to achieve softer features. The implants are inserted during surgery using general anesthesia and there is risk of extrusion, movement and infection, consequently they are not a treatment of choice.Polymethacrylate (PMMA): A report presented at a congress of a non-controlled trial carried out in Brazil which included 184 patients who received PMMA was found. Lipodystrophy correction was aesthetically good, long-lasting and with few adverse effects. Some patients required new injections after 13 to 18 months. The level of patient satisfaction was good and they expressed improvement in quality of life. PMMA has demonstrated long-lasting effects when compared with polylactic acid or fat implants. Because PMMA is diluted in a cheap polysacarid gel, it is probably more cost-effective than many of the previously described options.