ATLANTA – Bariatric surgery was associated with lowered viral loads and resolution of some antiretroviral-related comorbidities, such as type 2 diabetes, in patients with the human immunodeficiency virus, according to Dr. Raul J. Rosenthal.
Patients with HIV who have extended their life expectancy through highly antiretroviral treatment are now living long enough to develop lipohypertrophy, similar to metabolic syndrome, said Dr. Rosenthal, a bariatric surgeon at the Cleveland Clinic Florida in Weston.
"[Some obese patients with HIV] are developing hypertriglyceridemia, type 2 diabetes, hypercholesterolemia, and coronary artery disease," said Dr. Rosenthal. "We are not surprised that infectious disease and primary care doctors send these patients to us for surgery."
Dr. Raul Rosenthal
To determine whether bariatric surgery was improving the course of the HIV infection in this patient population, Dr. Rosenthal and his associates reviewed the records of 11 asymptomatic patients with HIV who underwent a bariatric procedure at a single surgery center in the past 10 years.
The researchers found that none of the patients had perioperative complications, and all reduced their preoperative mean body mass index (BMI) from 52 kg/m2 to 36 kg/m2. The patients’ preoperative mean weight dropped, on average, by 50%, Dr. Rosenthal said at the meeting, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
The patients’ total preoperative mean CD4 count went from 825 cells/mm3 to 504 cells/mm3; the viral load went from a preoperative mean of 813 copies/mL plasma to 684 copies/mL plasma. "I think this is the most important part of the whole study," said Dr. Rosenthal, who said that in patients with the HIV infection, it is important to always keep the CD4 (T-cell) level above 200 cells/mm3 and the viral load under 10,000 copies/mL plasma.
Five patients were followed for 2 years postoperatively. None had complications, although one patient did experience a long-term marginal ulcer with malnutrition.
Although the literature about bariatric surgery in this patient population is "scant" said Dr. Rosenthal, the data from his study were comparable to the findings from at least two other small studies that indicated bariatric surgery may be an effective treatment for obesity and its attendant comorbidities in HIV, without negatively impacting virologic suppression (Surg. Obes. Relat. Dis. 2005;1:73-6).
The best bariatric treatment in this patient population may be the sleeve because it was the least likely to preclude future treatments.
"The sleeve has a morbidity rate of 1.6%, and I am not going to fight that," given the unpredictable prognosis in this patient population, Dr. Rosenthal said.
Although larger studies are necessary, "so far, HIV does not appear to increase the rate of perioperative complications, and it does alter the course of HIV infection," he noted.