Avoidance of lipodystrophy would require a good understanding of the causes of lipodystrophy. Unfortunately, this is a science that is still in evolution; good data will require long-term prospective studies looking at persons on different drug regimens.
What we do know is that the biggest apparent risk for lipodystrophy has to do with long-term survival (see, for example Lichtenstein, CROI9) and that persons with low CD4 count nadirs (lowest ever value) seem to have much greater risk of having lipodystrophy. It seems like there may be drug factors; both d4T and indinavir have been implicated. What is less clear is if these associations are associations of long-term survival or actual drug effects, per se. Recent data presented at this year's retroconference seems to provide evidence that d4T may account for at least some lipoatrophy in persons taking this drug. It is important to state that this doesn't mean that everyone taking d4T will develop lipoatrophy, nor does it mean that if you don't take d4T, you won't develop lipodystrophy. We have a patient in our practice who has only taken AZT in the remote past, who has lipodystrophy-- just to make the point.
So, based on this, I'd advise you to avoid having a very low CD4 count-- this means not waiting too long to start on meds. Given the current data, d4T seems to be in question. If there is an equivalent option for you (specifically for you), then avoidance might make sense. I'm certainly waiting for additional data to confirm these findings; we need to know the best times and situations to use the available drugs that we have.
Good luck, BY
