Journal of Visceral Surgery (2015) 152, 33—37
Available online at
ScienceDirect www.sciencedirect.com
REVIEW
Obesity in HIV-infected patients in France: Prevalence and surgical treatment options G. Pourcher a,∗, D. Costagliola b,c,d, V. Martinez c,d a
Service de Chirurgie Digestive minimale invasive, AP—HP, Université Paris Sud, Inserm U972, Hôpital Antoine-Béclère, 157, rue de la Porte-de-Trivaux, 92141 Clamart, France b Inserm U943, 75013 Paris, France c UPMC Université Paris 06 UMR S943, 75013 Paris, France d AP—HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Maladies Infectieuses, 75013 Paris, France Available online 4 February 2015
KEYWORDS HIV infection; Obesity; Prevalence; Sleeve gastrectomy
Summary Increasing rate of obesity was reported in HIV-infected patients in USA. In France, no data are available to date. Bariatric surgery is the best option for morbid obesity in general population but few data exist in HIV-infected patients. We describe the prevalence of obesity in France in HIV-infected patients. The prevalence of obesity is 15.1% in women and 5.3% in men. Moreover, we described our experience and point of view in the management of HIV infected patients with morbid obesity. Prospective studies are needed for an optimal management of HIV-infected patients with morbid obesity. © 2014 Elsevier Masson SAS. All rights reserved.
Introduction The advent of combined anti-retroviral therapy (cART) has dramatically reduced the progression of HIV/AIDS. HIV-infected patients now live longer and may develop obesity and similar obesity-related co-morbidities similar to the general population [1]. Co-morbidities such as diabetes, insulin resistance, coronary artery disease, hypertension and neoplasia have been described in the HIV population for more than 10 years. These diseases have a multifactorial origin: immune activation, inflammation, role of the virus, anti-retroviral drugs, aging. . . In the general population, several studies have shown a positive association between obesity and increased rate of death, cardiovascular and metabolic diseases and neoplasia, particularly in patients with a BMI of ≥ 35 kg/m2 [2—5]. Bariatric surgery is considered as the gold standard of treatment to obtain long-term weight loss with reduced mortality and morbidity in the general population. No data have been published concerning the group of HIV-infected patients with obesity.
∗
Corresponding author. E-mail address: [email protected] (G. Pourcher).
http://dx.doi.org/10.1016/j.jviscsurg.2014.12.001 1878-7886/© 2014 Elsevier Masson SAS. All rights reserved.
34
G. Pourcher et al.
Prevalence of obesity in HIV-infected patients worldwide
obesity in African women. Similar results have been reported in Africa and in African women living in the USA [8,12].
The prevalence of obesity (defined by the World Health Organization as a body mass index (BMI) above 30 kg/m2 in the general population) was 27% in USA and 15% in France [6,7]. In the HIV population, few data have been published to date. In the USA, HIV-infected patients are increasingly overweight at diagnosis and during HIV infection [1]. The prevalence of overweight/obesity is between 9 to 37% [1,8—10]. The latest data presented to the International AIDS Society conference (Kuala Lumpur, Malaysia, 2013) showed a prevalence of 24% in North Carolina, 17% for men and 38% for women [8]. Few studies have examined disparities in weight change in HIV-seropositive cohorts. In this cohort from North Carolina, Afro-American women had a higher prevalence of 41% [8]. More recently, Taylor et al. reported that obesity and HIV disproportionately affect minorities and result in significant health risks [11]. In this study, we try to determine racial and health insurance disparities with regard to significant weight gain in a predominately Hispanic (63% Hispanic and 14% black) observational HIV cohort of 1214 non-underweight HIV patients, from 2007 to 2010. In this majority Hispanic HIV cohort, 60% were overweight or obese at baseline, and uninsured minority patients gained weight more rapidly [11]. The ethnic disparities observed in the prevalence of obesity in HIVinfected patients, played no role in the choice of surgical procedure.
Prevalence of obesity in HIV+ patients in France In France, no data have been published to date. In the French Hospital Database on HIV (FHDH, ANRS CO4), 48,897 patients were followed in 2010 including 37,505 with weight and height data. Ninety-eight percent of patients were infected with HIV-1 strain. Thirty-three percent were female, 62% were 40 years of age or less, 17% were born in Sub-Saharan Africa, 45% were heterosexual patients. Twenty-five percent were considered to have AIDS. Eightyseven percent of patients were treated with cART, 53% had a CD4 count above 500/mm3 and 77% had a plasma viral load < 50 copies/ml. The prevalence of obesity was 15% in women and 5% in men. Patients born in Sub-Saharan Africa were more likely to be obese (21% versus 12% in women and 11% versus 5% in men) (Table 1). The data reported in the FHDH for HIV patients were similar to those published in France for the general population globally and in the same age ranges [6]. In this cohort, we observed a higher prevalence of Table 1
Variations of BMI according to patient’s origin. 2
BMI (kg/m )
BMI < 21 BMI ≥ 30 21 ≤ BMI < 24 24 ≤ BMI < 27 27 ≤ BMI < 30 Total
Sub-Saharan Africa origin
Other origins
n
%
n
%
844 1109 1666 1664 1199 6482
13 17 26 26 18 100
8245 2060 10,880 6967 2871 31,023
27 7 35 22 9 100
Obesity and/or HIV-associated diseases In the general population, obesity is associated with chronic systemic inflammation that influences the development of obesity-related co-morbidities such as hypertension, diabetes, heart disease and neoplasia [3]. In the same way, HIV infection is associated with chronic inflammation resulting in similar complications [5,13,14]. HIV-infected patients with normal weight develop the same cardiovascular and metabolic diseases [11,13—15]. Probably, the obese HIVinfected patients have an increased risk but no data have been reported about these complications. This weight gain appears to reflect improved health status due to decreased HIV-related morbidity, with increased life span, quality of life mirroring trends in the general population [1,10]. Moreover, Crum-Cianflone et al. reported that obese versus normal weight HIV-infected patients treated by cART had a smaller increase in CD4 cell counts, which they considered as an other adverse consequence of obesity [16].
What are the indications for bariatric surgery in HIV-infected patients? Bariatric surgery is considered as the best treatment option for morbid obesity (BMI > 40 kg/m2 or > 35 kg/m2 with comorbidities) in international and national guidelines for the general population [17,18]. This surgery is associated with long-term weight loss, decreased overall mortality and morbidity, and particularly, resolution of diabetes and dyslipidemia [17—21]. Three surgical methods are used today: gastric banding (pure restrictive method), gastro-jejunal bypass (restrictive and malabsorptive method) and sleeve gastrectomy (restrictive and endocrine method). Performance of bariatric surgery in patients with HIV infection is debated. Despite key benefits of surgery in the general population and an important prevalence of obesity in HIV-infected patients, few data are available about bariatric procedures in obese HIV-infected patients and these involve only malabsorptive procedures [22—24]. A retrospective study reported six patients who underwent Roux-en-Y gastric bypass. Their mean preoperative BMI was 50 kg/m2 (range, 42—59) and all patients had comorbidities: type 2 diabetes mellitus, impaired glucose tolerance, hypertension, dyslipidemia, coronary artery disease/chronic heart failure [23]. Thirty-three percent were receiving cART at the time of surgery with a mean CD4 cell count of 619/mm3 (range, 361—1096/mm3 ). There were no deaths or postoperative infectious complications. Mean percent excess body weight loss was 33% at 3 months, 47% at 6 months, and 61% at 12 months [23]. Selke et al., reported seven subjects with HIV infection who underwent gastric bypass [24]. Viral suppression was maintained in five of the six subjects who were receiving cART prior to surgery, including three subjects who experienced surgical complications. The median decrease in BMI postoperatively was 10 kg/m2 (range, 6—28). No study has reported the use of sleeve gastrectomy in HIV-infected patients. In our minimal invasive surgical center, bariatric surgery was performed in HIV-infected patients using laparoscopic
Bariatric surgery in obese HIV patients procedures like those used for all obese patients. We have the experience of six patients who underwent a sleeve gastrectomy. For four of them (1 man and 3 African women, median age 37.5 years, median BMI: 48 kg/m2 ), we have long-term follow-up before (6—12 months) and after surgery (18—36 months). Two patients have co-morbidities: one with hypertension treated with perindopril/valsartan and sleep apnea treated with night-time CPAP and the second with treated sleep apnea. Before surgery, two patients were receiving anti-retroviral therapy. All patients had a CD4 count > 475/mm3 and laboratory parameters were within normal range. Median percent excess body weight loss was 61%, at 18 or 36 months after the surgery. All co-morbidities resolved with weight loss at 6 months. Success of surgery was evaluated using the Baros score (quality of life, comorbidities and weight loss), as proposed [25]. The median Baros score was 7/9, corresponding to a good result [25]. No postoperative complication was reported and all patients were discharged at day 3 or 4. Using the patient as his own control, we observed no significant alterations of CD4 cell count and HIV plasma viral load before and after the surgery.
How to select patients with a reduced peroperative risk? Criteria for patient selection should not differ from those used in the general population. Surgery is considered as the gold standard according to French and International recommendations [26—29] for morbid obesity (BMI ≥ 40 kg/m2 ) resistant to conventional therapy and for obesity with BMI between 35 and 40 kg/m2 associated with co-morbidity: cardiovascular, metabolic, articular diseases. The surgery can be performed after a follow-up of at least 6 months. Depending on the severity of HIV infection and in order to reduce operative and postoperative risk, we preferred to choose patients between 18 and 65 years with undetectable HIV plasma viral load, a CD4 cell count > 250/mm3 , stabilized with cART treatment for at least 12 months, with a Karnofsky index > 80% and without uncontrolled infection. All of those conditions must be discussed and concerted with an HIV specialist to more accurately evaluate each patient before the surgery in coordination with multidisciplinary staff.
35 virological and pharmacokinetic data [22—24]. In the general population, sleeve gastrectomy has a similar efficacy to gastro-jejunal bypass, with regard to weight loss and management of metabolic disorders in medium and long-term follow-up [20,30,31]. Compared to gastric bypass, sleeve gastrectomy preserves digestive continuity and induces less malabsorption, vitamin deficiency and fewer complications (diarrhea, dumping syndrome, occlusion and late complications) and allows a better quality of life in medium and long-term follow-up [31—37]. The most recent international recommendations recommend that patients who undergo gastric bypass (as opposed to sleeve gastrectomy) should have screening and lifelong oral calcium citrate and vitamin D supplementation (ergocalciferol or cholecalciferol) to prevent or minimize secondary hyperparathyroidism, as well as daily oral supplementation with crystalline vitamin B12 and periodic bone density measurements [38]. For sleeve gastrectomy, vitamin supplementation is discussed on a case-by-case basis. The consequences of vitamin B12, B9, and D malabsorption are suppressed with sleeve gastrectomy [32]. This fact is important regardless the frequency of vitamin D, B12 and B9 deficiency related to HIV infection or medications [39—41]. Moreover, the performance of a malabsorptive procedure could impact the absorption of anti-retroviral drugs with a potential risk of failure of virological control. Whatever bariatric method is used, the pharmacokinetics of cART and HIV plasma viral load must be evaluated before and after surgery to adapt the therapy and to avoid virological failure. Recent data have shown that bariatric surgery including sleeve gastrectomy achieves glycemic control in type 2 diabetes in significantly more patients than medical therapy alone [21]. In addition to positive metabolic effects, sleeve gastrectomy has been used as a first-step approach for morbidly obese patients with malignancies who require rapid weight loss before a final curative procedure or for pretransplant candidates [42—44]. The last advantage of sleeve gastrectomy is that the procedure is feasible with single-port techniques corresponding to a surgery with only a single centimetric incision [37]. This new option for sleeve gastrectomy, in addition to the advantages of a minimally invasive concept in fragile patients, could be permit an easier and secure extraction of the gastric specimen. Single-port sleeve gastrectomy therefore appears to be safe and effective, with similar results to conventional laparoscopy and has the advantage of better cosmesis [17,36,44].
Risk, benefit and choice of the surgical method
Conclusion
According to all reported data, HIV-infected patients must be managed at least similarly to the general population. Nevertheless, co-morbidities that develop in non-obese patients with HIV without obesity make it all the more imperative to manage weight gain in HIV-infected patients. For HIV-infected patients, we need to choose a safe procedure, with no disruption of intestinal continuity, without implanted foreign material, that results in less malabsorption and has long-term weight loss efficacy. Sleeve gastrectomy is an emerging procedure for the treatment of obesity that provides rapid and satisfactory weight loss without malabsorption. Sleeve gastrectomy could be considered as the best option in HIV-infected patients. In the context of HIV infection, only gastric bypass have been published in very small studies without immunological,
Weight management programs may be important components of overall HIV care, particularly in countries where obesity is prevalent. Nevertheless, such bariatric procedures remain very marginal at this time. For all of these reasons, in morbidly obese HIV-infected patients, sleeve gastrectomy appears as a good therapeutic option since it avoids malabsorption and possible modifications of antiretroviral drug absorption, has fewer complications and offers better quality of life. Additional prospective studies are required to determine whether sleeve gastrectomy significantly improves outcomes and satisfaction in the HIVinfected patient. Prospective studies are needed to propose an optimal management of HIV-infected patients with morbid obesity.
36
G. Pourcher et al.
ESSENTIAL POINTS • An increasing rate of obesity is reported in HIVinfected patients in the USA. • In France, no data are available to date. The prevalence of obesity is 15.1% in women and 5.3% in men in the French Hospital Database on HIV (FHDH, ANRS CO4). • Higher prevalence is observed in patients born in Sub-Saharan Africa. • Bariatric surgery is the best option for morbid obesity in the general population but few data exist for HIV-infected patients. • Sleeve gastrectomy could be the best choice for obese HIV-infected patients resulting in less malabsorption, no disruption of continuity, better quality of life and similar weight loss efficacy. • Prospective studies are needed to define optimal management of HIV-infected patients with morbid obesity.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Crum-Cianflone N, Roediger MP, Eberly L, et al. Increasing rates of obesity among HIV-infected persons during the HIV epidemic. PLoS One 2010;5:e10106. [2] Adams KF, Schatzkin A, Harris TB, et al. Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. N Engl J Med 2006;355:763—78. [3] Eeg-Olofsson K, Cederholm J, Nilsson PM, et al. Risk of cardiovascular disease and mortality in overweight and obese patients with type 2 diabetes: an observational study in 13,087 patients. Diabetologia 2009;52:65—73. [4] Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA 2005;293:1861—7. [5] Grinspoon S. Diabetes mellitus, cardiovascular risk, and HIV disease. Circulation 2009;119:770—2. [6] Obépi Roche. Enquête épidémiologique nationale sur le surpoids et l’obésité. INSERM/TNS HEALTHCARE (KANTARHEALTH)/ROCHE; 2012. [7] Sherry B, Blanck HM, Galuska DA, Pan L, Dietz WH, Balluz L. Morbidity and Mortality Weekly Report. Vital signs: state-specific obesity prevalence among adults. United States: Centers for Disease Control; 2009 [In; 2010]. [8] Menezes PJK, Wohl D, Eron J. Obesity prevalence and cumulative antiretroviral exposure among HIV-positive adults in clinical care at University of North Carolina, 2004—2010. Kuala Lumpur, Malaysia: IAS; 2013. [9] Amorosa V, Synnestvedt M, Gross R, et al. A tale of 2 epidemics: the intersection between obesity and HIV infection in Philadelphia. J Acquir Immune Defic Syndr 2005;39:557—61. [10] Crum-Cianflone N, Tejidor R, Medina S, Barahona I, Ganesan A. Obesity among patients with HIV: the latest epidemic. AIDS Patient Care STDS 2008;22:925—30. [11] Taylor BS, Liang Y, Garduno LS, et al. High risk of obesity and weight gain for HIV-infected uninsured minorities. J Acquir Immune Defic Syndr 2014;65:e33—40. [12] Malaza A, Mossong J, Barnighausen T, Newell ML. Hypertension and obesity in adults living in a high HIV prevalence rural area in South Africa. PLoS One 2012;7:e47761.
[13] De Socio GV, Ricci E, Maggi P, et al. Prevalence, awareness, treatment, and control rate of hypertension in HIV-infected patients: the HIV-HY study. Am J Hypertens 2014;27:222—8. [14] Hemkens LG, Bucher HC. HIV infection and cardiovascular disease. Eur Heart J 2014;35:1373—81. [15] Lake JE, Tseng CH, Currier JS. A pilot study of telmisartan for visceral adiposity in HIV infection: the metabolic abnormalities, telmisartan, and HIV infection (MATH) trial. PLoS One 2013;8:e58135. [16] Crum-Cianflone NF, Roediger M, Eberly LE, et al. Obesity among HIV-infected persons: impact of weight on CD4 cell count. AIDS 2010;24:1069—72. [17] Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity. Cochrane Database Syst Rev 2009;2:CD003641. [18] Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357:741—52. [19] Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med 2007;357:753—61. [20] Perathoner A, Weissenbacher A, Sucher R, Laimer E, Pratschke J, Mittermair R. Significant Weight Loss and Rapid Resolution of Diabetes and Dyslipidemia During Short-Term Follow-Up After Laparoscopic Sleeve Gastrectomy. Obes Surg 2013;23:1966—72. [21] Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012;366:1567—76. [22] Fazylov R, Soto E, Merola S. Laparoscopic gastric bypass surgery in human immunodeficiency virus-infected patients. Surg Obes Relat Dis 2007;3:637—9. [23] Flancbaum L, Drake V, Colarusso T, Belsley S. Initial experience with bariatric surgery in asymptomatic human immunodeficiency virus-infected patients. Surg Obes Relat Dis 2005;1:73—6. [24] Selke H, Norris S, Osterholzer D, Fife KH, DeRose B, Gupta SK. Bariatric surgery outcomes in HIV-infected subjects: a case series. AIDS Patient Care STDS 2010;24:545—50. [25] Oria HE, Moorehead MK. Bariatric analysis and reporting outcome system (BAROS). Obes Surg 1998;8:487—99. [26] National Institute for Health and Clinical Excellence. Obesity guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. NICE clinical guideline 43; 2006. [27] HAS. Gastrectomie longitudinale [sleeve gastrectomy] pour obésité. Rapport d’évaluation technologique. Saint-Denis La Plaine: HAS; 2008. [28] HAS. Obésité : prise en charge chirurgicale chez l’adulte. Interventions initiales et reinterventions. Saint-Denis: HAS; 2009. p. 1—263. [29] OMS. Le défi de l’obésité dans la région européenne de l’OMS et les stratégies de lutte. Genève: OMS; 2007. [30] Keidar A, Hershkop KJ, Marko L, et al. Roux-en-Y gastric bypass vs sleeve gastrectomy for obese patients with type 2 diabetes: a randomised trial. Diabetologia 2013;56:1914—8. [31] Peterli R, Borbely Y, Kern B, et al. Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Ann Surg 2013;258:690—4. [32] Alvarez-Leite JI. Nutrient deficiencies secondary to bariatric surgery. Curr Opin Clin Nutr Metab Care 2004;7:569—75. [33] Brunault P, Jacobi D, Leger J, et al. Observations regarding ‘quality of life’ and ‘comfort with food’ after bariatric surgery: comparison between laparoscopic adjustable gastric banding and sleeve gastrectomy. Obes Surg 2011;21:1225—31. [34] Chouillard EK, Karaa A, Elkhoury M, Greco VJ. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for morbid obesity: case-control study. Surg Obes Relat Dis 2011;7:500—5. [35] Gehrer S, Kern B, Peters T, Christoffel-Courtin C, Peterli R. Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux-Y-gastric bypass (LRYGB): a prospective study. Obes Surg 2010;20: 447—53.
Bariatric surgery in obese HIV patients [36] Helmio M, Victorzon M, Ovaska J, et al. SLEEVEPASS: a randomized prospective multicenter study comparing laparoscopic sleeve gastrectomy and gastric bypass in the treatment of morbid obesity: preliminary results. Surg Endosc 2012;26:2521—6. [37] Pourcher G, Di Giuro G, Lafosse T, Lainas P, Naveau S, Dagher I. Routine single-port sleeve gastrectomy: a study of 60 consecutive patients. Surg Obes Relat Dis 2013;9:385—9. [38] Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient: 2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity 2013;21(Suppl 1):S1—27. [39] Paltiel O, Falutz J, Veilleux M, Rosenblatt DS, Gordon K. Clinical correlates of subnormal vitamin B12 levels in patients infected with the human immunodeficiency virus. Am J Hematol 1995;49:318—22.
37 [40] Boudes P, Zittoun J, Sobel A. Folate, vitamin B12, and HIV infection. Lancet 1990;335:1401—2. [41] Mueller NJ, Fux CA, Ledergerber B, et al. High prevalence of severe vitamin D deficiency in combined antiretroviral therapy-naive and successfully treated Swiss HIV patients. AIDS 2010;24:1127—34. [42] Gianos M, Abdemur A, Szomstein S, Rosenthal R. Laparoscopic sleeve gastrectomy as a step approach for morbidly obese patients with early stage malignancies requiring rapid weight loss for a final curative procedure. Obes Surg 2013;23: 1370—4. [43] Lin MY, Tavakol MM, Sarin A, et al. Laparoscopic sleeve gastrectomy is safe and efficacious for pretransplant candidates. Surg Obes Relat Dis 2013;9:653—8. [44] Lin MY, Tavakol MM, Sarin A, et al. Safety and feasibility of sleeve gastrectomy in morbidly obese patients following liver transplantation. Surg Endosc 2013;27:81—5.
Available online at
ScienceDirect www.sciencedirect.com
REVIEW
Obesity in HIV-infected patients in France: Prevalence and surgical treatment options G. Pourcher a,∗, D. Costagliola b,c,d, V. Martinez c,d a
Service de Chirurgie Digestive minimale invasive, AP—HP, Université Paris Sud, Inserm U972, Hôpital Antoine-Béclère, 157, rue de la Porte-de-Trivaux, 92141 Clamart, France b Inserm U943, 75013 Paris, France c UPMC Université Paris 06 UMR S943, 75013 Paris, France d AP—HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Maladies Infectieuses, 75013 Paris, France Available online 4 February 2015
KEYWORDS HIV infection; Obesity; Prevalence; Sleeve gastrectomy
Summary Increasing rate of obesity was reported in HIV-infected patients in USA. In France, no data are available to date. Bariatric surgery is the best option for morbid obesity in general population but few data exist in HIV-infected patients. We describe the prevalence of obesity in France in HIV-infected patients. The prevalence of obesity is 15.1% in women and 5.3% in men. Moreover, we described our experience and point of view in the management of HIV infected patients with morbid obesity. Prospective studies are needed for an optimal management of HIV-infected patients with morbid obesity. © 2014 Elsevier Masson SAS. All rights reserved.
Introduction The advent of combined anti-retroviral therapy (cART) has dramatically reduced the progression of HIV/AIDS. HIV-infected patients now live longer and may develop obesity and similar obesity-related co-morbidities similar to the general population [1]. Co-morbidities such as diabetes, insulin resistance, coronary artery disease, hypertension and neoplasia have been described in the HIV population for more than 10 years. These diseases have a multifactorial origin: immune activation, inflammation, role of the virus, anti-retroviral drugs, aging. . . In the general population, several studies have shown a positive association between obesity and increased rate of death, cardiovascular and metabolic diseases and neoplasia, particularly in patients with a BMI of ≥ 35 kg/m2 [2—5]. Bariatric surgery is considered as the gold standard of treatment to obtain long-term weight loss with reduced mortality and morbidity in the general population. No data have been published concerning the group of HIV-infected patients with obesity.
∗
Corresponding author. E-mail address: [email protected] (G. Pourcher).
http://dx.doi.org/10.1016/j.jviscsurg.2014.12.001 1878-7886/© 2014 Elsevier Masson SAS. All rights reserved.
34
G. Pourcher et al.
Prevalence of obesity in HIV-infected patients worldwide
obesity in African women. Similar results have been reported in Africa and in African women living in the USA [8,12].
The prevalence of obesity (defined by the World Health Organization as a body mass index (BMI) above 30 kg/m2 in the general population) was 27% in USA and 15% in France [6,7]. In the HIV population, few data have been published to date. In the USA, HIV-infected patients are increasingly overweight at diagnosis and during HIV infection [1]. The prevalence of overweight/obesity is between 9 to 37% [1,8—10]. The latest data presented to the International AIDS Society conference (Kuala Lumpur, Malaysia, 2013) showed a prevalence of 24% in North Carolina, 17% for men and 38% for women [8]. Few studies have examined disparities in weight change in HIV-seropositive cohorts. In this cohort from North Carolina, Afro-American women had a higher prevalence of 41% [8]. More recently, Taylor et al. reported that obesity and HIV disproportionately affect minorities and result in significant health risks [11]. In this study, we try to determine racial and health insurance disparities with regard to significant weight gain in a predominately Hispanic (63% Hispanic and 14% black) observational HIV cohort of 1214 non-underweight HIV patients, from 2007 to 2010. In this majority Hispanic HIV cohort, 60% were overweight or obese at baseline, and uninsured minority patients gained weight more rapidly [11]. The ethnic disparities observed in the prevalence of obesity in HIVinfected patients, played no role in the choice of surgical procedure.
Prevalence of obesity in HIV+ patients in France In France, no data have been published to date. In the French Hospital Database on HIV (FHDH, ANRS CO4), 48,897 patients were followed in 2010 including 37,505 with weight and height data. Ninety-eight percent of patients were infected with HIV-1 strain. Thirty-three percent were female, 62% were 40 years of age or less, 17% were born in Sub-Saharan Africa, 45% were heterosexual patients. Twenty-five percent were considered to have AIDS. Eightyseven percent of patients were treated with cART, 53% had a CD4 count above 500/mm3 and 77% had a plasma viral load < 50 copies/ml. The prevalence of obesity was 15% in women and 5% in men. Patients born in Sub-Saharan Africa were more likely to be obese (21% versus 12% in women and 11% versus 5% in men) (Table 1). The data reported in the FHDH for HIV patients were similar to those published in France for the general population globally and in the same age ranges [6]. In this cohort, we observed a higher prevalence of Table 1
Variations of BMI according to patient’s origin. 2
BMI (kg/m )
BMI < 21 BMI ≥ 30 21 ≤ BMI < 24 24 ≤ BMI < 27 27 ≤ BMI < 30 Total
Sub-Saharan Africa origin
Other origins
n
%
n
%
844 1109 1666 1664 1199 6482
13 17 26 26 18 100
8245 2060 10,880 6967 2871 31,023
27 7 35 22 9 100
Obesity and/or HIV-associated diseases In the general population, obesity is associated with chronic systemic inflammation that influences the development of obesity-related co-morbidities such as hypertension, diabetes, heart disease and neoplasia [3]. In the same way, HIV infection is associated with chronic inflammation resulting in similar complications [5,13,14]. HIV-infected patients with normal weight develop the same cardiovascular and metabolic diseases [11,13—15]. Probably, the obese HIVinfected patients have an increased risk but no data have been reported about these complications. This weight gain appears to reflect improved health status due to decreased HIV-related morbidity, with increased life span, quality of life mirroring trends in the general population [1,10]. Moreover, Crum-Cianflone et al. reported that obese versus normal weight HIV-infected patients treated by cART had a smaller increase in CD4 cell counts, which they considered as an other adverse consequence of obesity [16].
What are the indications for bariatric surgery in HIV-infected patients? Bariatric surgery is considered as the best treatment option for morbid obesity (BMI > 40 kg/m2 or > 35 kg/m2 with comorbidities) in international and national guidelines for the general population [17,18]. This surgery is associated with long-term weight loss, decreased overall mortality and morbidity, and particularly, resolution of diabetes and dyslipidemia [17—21]. Three surgical methods are used today: gastric banding (pure restrictive method), gastro-jejunal bypass (restrictive and malabsorptive method) and sleeve gastrectomy (restrictive and endocrine method). Performance of bariatric surgery in patients with HIV infection is debated. Despite key benefits of surgery in the general population and an important prevalence of obesity in HIV-infected patients, few data are available about bariatric procedures in obese HIV-infected patients and these involve only malabsorptive procedures [22—24]. A retrospective study reported six patients who underwent Roux-en-Y gastric bypass. Their mean preoperative BMI was 50 kg/m2 (range, 42—59) and all patients had comorbidities: type 2 diabetes mellitus, impaired glucose tolerance, hypertension, dyslipidemia, coronary artery disease/chronic heart failure [23]. Thirty-three percent were receiving cART at the time of surgery with a mean CD4 cell count of 619/mm3 (range, 361—1096/mm3 ). There were no deaths or postoperative infectious complications. Mean percent excess body weight loss was 33% at 3 months, 47% at 6 months, and 61% at 12 months [23]. Selke et al., reported seven subjects with HIV infection who underwent gastric bypass [24]. Viral suppression was maintained in five of the six subjects who were receiving cART prior to surgery, including three subjects who experienced surgical complications. The median decrease in BMI postoperatively was 10 kg/m2 (range, 6—28). No study has reported the use of sleeve gastrectomy in HIV-infected patients. In our minimal invasive surgical center, bariatric surgery was performed in HIV-infected patients using laparoscopic
Bariatric surgery in obese HIV patients procedures like those used for all obese patients. We have the experience of six patients who underwent a sleeve gastrectomy. For four of them (1 man and 3 African women, median age 37.5 years, median BMI: 48 kg/m2 ), we have long-term follow-up before (6—12 months) and after surgery (18—36 months). Two patients have co-morbidities: one with hypertension treated with perindopril/valsartan and sleep apnea treated with night-time CPAP and the second with treated sleep apnea. Before surgery, two patients were receiving anti-retroviral therapy. All patients had a CD4 count > 475/mm3 and laboratory parameters were within normal range. Median percent excess body weight loss was 61%, at 18 or 36 months after the surgery. All co-morbidities resolved with weight loss at 6 months. Success of surgery was evaluated using the Baros score (quality of life, comorbidities and weight loss), as proposed [25]. The median Baros score was 7/9, corresponding to a good result [25]. No postoperative complication was reported and all patients were discharged at day 3 or 4. Using the patient as his own control, we observed no significant alterations of CD4 cell count and HIV plasma viral load before and after the surgery.
How to select patients with a reduced peroperative risk? Criteria for patient selection should not differ from those used in the general population. Surgery is considered as the gold standard according to French and International recommendations [26—29] for morbid obesity (BMI ≥ 40 kg/m2 ) resistant to conventional therapy and for obesity with BMI between 35 and 40 kg/m2 associated with co-morbidity: cardiovascular, metabolic, articular diseases. The surgery can be performed after a follow-up of at least 6 months. Depending on the severity of HIV infection and in order to reduce operative and postoperative risk, we preferred to choose patients between 18 and 65 years with undetectable HIV plasma viral load, a CD4 cell count > 250/mm3 , stabilized with cART treatment for at least 12 months, with a Karnofsky index > 80% and without uncontrolled infection. All of those conditions must be discussed and concerted with an HIV specialist to more accurately evaluate each patient before the surgery in coordination with multidisciplinary staff.
35 virological and pharmacokinetic data [22—24]. In the general population, sleeve gastrectomy has a similar efficacy to gastro-jejunal bypass, with regard to weight loss and management of metabolic disorders in medium and long-term follow-up [20,30,31]. Compared to gastric bypass, sleeve gastrectomy preserves digestive continuity and induces less malabsorption, vitamin deficiency and fewer complications (diarrhea, dumping syndrome, occlusion and late complications) and allows a better quality of life in medium and long-term follow-up [31—37]. The most recent international recommendations recommend that patients who undergo gastric bypass (as opposed to sleeve gastrectomy) should have screening and lifelong oral calcium citrate and vitamin D supplementation (ergocalciferol or cholecalciferol) to prevent or minimize secondary hyperparathyroidism, as well as daily oral supplementation with crystalline vitamin B12 and periodic bone density measurements [38]. For sleeve gastrectomy, vitamin supplementation is discussed on a case-by-case basis. The consequences of vitamin B12, B9, and D malabsorption are suppressed with sleeve gastrectomy [32]. This fact is important regardless the frequency of vitamin D, B12 and B9 deficiency related to HIV infection or medications [39—41]. Moreover, the performance of a malabsorptive procedure could impact the absorption of anti-retroviral drugs with a potential risk of failure of virological control. Whatever bariatric method is used, the pharmacokinetics of cART and HIV plasma viral load must be evaluated before and after surgery to adapt the therapy and to avoid virological failure. Recent data have shown that bariatric surgery including sleeve gastrectomy achieves glycemic control in type 2 diabetes in significantly more patients than medical therapy alone [21]. In addition to positive metabolic effects, sleeve gastrectomy has been used as a first-step approach for morbidly obese patients with malignancies who require rapid weight loss before a final curative procedure or for pretransplant candidates [42—44]. The last advantage of sleeve gastrectomy is that the procedure is feasible with single-port techniques corresponding to a surgery with only a single centimetric incision [37]. This new option for sleeve gastrectomy, in addition to the advantages of a minimally invasive concept in fragile patients, could be permit an easier and secure extraction of the gastric specimen. Single-port sleeve gastrectomy therefore appears to be safe and effective, with similar results to conventional laparoscopy and has the advantage of better cosmesis [17,36,44].
Risk, benefit and choice of the surgical method
Conclusion
According to all reported data, HIV-infected patients must be managed at least similarly to the general population. Nevertheless, co-morbidities that develop in non-obese patients with HIV without obesity make it all the more imperative to manage weight gain in HIV-infected patients. For HIV-infected patients, we need to choose a safe procedure, with no disruption of intestinal continuity, without implanted foreign material, that results in less malabsorption and has long-term weight loss efficacy. Sleeve gastrectomy is an emerging procedure for the treatment of obesity that provides rapid and satisfactory weight loss without malabsorption. Sleeve gastrectomy could be considered as the best option in HIV-infected patients. In the context of HIV infection, only gastric bypass have been published in very small studies without immunological,
Weight management programs may be important components of overall HIV care, particularly in countries where obesity is prevalent. Nevertheless, such bariatric procedures remain very marginal at this time. For all of these reasons, in morbidly obese HIV-infected patients, sleeve gastrectomy appears as a good therapeutic option since it avoids malabsorption and possible modifications of antiretroviral drug absorption, has fewer complications and offers better quality of life. Additional prospective studies are required to determine whether sleeve gastrectomy significantly improves outcomes and satisfaction in the HIVinfected patient. Prospective studies are needed to propose an optimal management of HIV-infected patients with morbid obesity.
36
G. Pourcher et al.
ESSENTIAL POINTS • An increasing rate of obesity is reported in HIVinfected patients in the USA. • In France, no data are available to date. The prevalence of obesity is 15.1% in women and 5.3% in men in the French Hospital Database on HIV (FHDH, ANRS CO4). • Higher prevalence is observed in patients born in Sub-Saharan Africa. • Bariatric surgery is the best option for morbid obesity in the general population but few data exist for HIV-infected patients. • Sleeve gastrectomy could be the best choice for obese HIV-infected patients resulting in less malabsorption, no disruption of continuity, better quality of life and similar weight loss efficacy. • Prospective studies are needed to define optimal management of HIV-infected patients with morbid obesity.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
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