Extra Chin
Garry, from Preston Vic, writes: I have noticed something unusual happening with my face recently – I seem to be developing a second chin. It is not a normal weight gain issue and I figure it is part of the lipodystrophy syndrome that I have heard so much about. I am on tenofovir and Kaletra and wonder whether going off any of these drugs would stop this problem from getting any worse. Do you know if there are plastic surgery interventions that could help with this condition?
Dr Nick replies: Of course it’s hard to be sure in writing what the physical appearance might be related to.
Body shape changes are very complicated as there are so many different things that have an effect on them. We have known about lipodystrophy for some years now, but we’re still in the process of sorting out what it is, what causes it, what prevents it and what, if anything, can be done about it.
The two main parts of lipodystrophy that affect body shape are peripheral lipoatrophy and central fat accumulation. The first is a loss of body fat and the second is a gain in body fat. One might hope that they might cancel each other out, but unfortunately they appear to affect different parts of the body. Peripheral lipoatrophy leads to loss of fat from under the skin, predominantly on the arms, legs, and face. Central fat accumulation occurs predominantly inside the abdomen, the breast, and perhaps the neck.
The nucleoside drugs, particularly stavudine (d4T, Zerit) and didanosine (ddI, Videx), are the drugs most implicated in causing lipoatrophy. It takes a long time for lipoatrophy to develop and it is equally slow to go away, if it does at all. So someone can still show the physical effects of having taken these drugs for some years after stopping them.
The mechanism behind abnormal fat accumulation is less clear. At least some of it might be what you call ‘normal weight gain’. But it is not normal weight gain for many people with HIV, which on the whole causes people to be underweight. Thinking of the virus as a drain on the body is one way to look at it.
Now for the really confusing bit. When many patients, after some years of being underweight, started antiretroviral therapy, they started to get the weight gain and the weight loss at the same time in different parts of the body. This possibly led to the classic ‘lipodystrophy’ physical body shape change.
Gritty Eye Problem
David, from Strawberry Hills NSW, writes: Every morning I wake up with gritty eyes and I find it very frustrating. I have to put eye drops in several times a day. My doctor says that it is an HIV-related issue that I am going to have to get used to – your eyes are drier just as your mouth is often drier because of HIV or the medications. I have tried a herb called Bilberry which has improved the problem a little but I wonder if you know of anything I can do to get rid of the condition?
Dr Nick replies: I’m not aware of HIV or antiviral medications causing dryness of the eye or mouth directly. However, there are a lot of other medications that can do this. You might like to ask your doctor if there are other medications, which might be able to be changed that would relieve the problem.
However, there is a condition called Sjogren’s syndrome which is more common in positive people than in the general community. In this condition the body’s own immune system attacks the salivary glands and the tear glands. If this is the cause of your problem, then I’m afraid there’s not a lot that can be done. It’s just a question of ameliorating the symptoms.
One significant issue is the health of your mouth and gums if you have dry mouth. People with HIV have higher oral health care needs than the general population. Regular checkups and dental care are necessary if you still want to be chomping on an apple when you’re an old man!
Sleep Disturbance
John, from Norwood SA, writes: I have been only able to get to sleep for periods of three hours at a time for the past year or so. I sometimes get six hours a night but it is broken sleep. I am 62 years old, on d4T, 3TC, Kaletra and tenofovir, a blood pressure tablet called Avapro and an antidepressant called Avanza. Do you think a combination of my age and some of those tablets are causing my sleep problems? I try to stay off sleeping tablets but even when I take them (I take Imovane) I don’t sleep that well. Can you suggest anything?
Dr Nick replies: I notice that one of the medications you are on is an antidepressant. Depression is a common condition which certainly causes insomnia, so that might be a connection. Avanza causes sedation in many people and actually assists sleep. Confusingly, however, in higher doses it can be stimulant. Perhaps you could discuss that issue with your doctor. Unfortunately we don’t have any good medical treatment for insomnia as such.
Sleeping tablets like Imovane help to relieve the symptom in insomnia in the very short term. However all sleeping tablets make insomnia worse in the long term by interfering with the body’s natural sleep mechanisms. If there’s not a medical basis to your insomnia, then you’re doctor isn’t going to be able to help you a lot, and nor am I.
Careful attention to other factors is important. Nicotine, alcohol and caffeine are all drugs which make insomnia worse in the short and long term. Many of us aren’t aware that our sleep environment isn’t ideal. Sound and light and temperature can subtly make our sleep lighter and more broken.
I can recommend a book called Say Goodnight to Insomnia by Gregg Jacobs and Herbert Benson, which is a practical six-week drug free guide to overcoming insomnia and the negative effects it has on your life. For better or for worse, this is likely to be a problem which your doctor can’t help you with, but which careful attention to by you can improve very significantly.
