Combination therapy for HIV (commonly called ART or HAART) is very effective and generally safe. One group, or class, of anti-HIV drugs is called nucleoside analogues (nukes). These were the first drugs licensed for HIV treatment and today form the backbone of combination therapy. In high-income countries such as Canada, Australia and Western Europe, commonly used combinations of nukes include the following:
- Truvada – a fixed-dose combination of two anti-HIV drugs: tenofovir + FTC
- Kivexa – a fixed-dose combination of two anti-HIV drugs: abavavir + 3TC
However, these nukes were not always in common use. In the past, some HIV-positive people had been exposed to other nukes, such as these:
- d4T (stavudine, Zerit)
- AZT (zidovudine, and also in Combivir and Trizivir)
Over a decade ago, the use of d4T (and to a lesser extent AZT) became linked to the loss of the fatty layer just under the skin (subcutaneous fat). The disappearance of subcutaneous fat from the face changes a person’s appearance and often leaves affected people deeply distressed. Also, often in such cases fat accumulates in the belly and sometimes at the back of the neck.
Reconstructive surgery to deal with the loss of subcutaneous fat in the face involved injection of facial fillers; commonly used products included poly-L-lactic acid (PLA, New-Fill, Sculptra). After a few years, PLA is absorbed into the body and new implants are needed.
Another product that was used in the past decade was polyalkylimide gel (PAIG, Bio-Alcamid). Initially it seemed that PAIG was advantageous to PLA because PAIG was a permanent implant and would not degrade. However, reports began to emerge from Western Europe of inflammation and infections in both HIV-negative and HIV-positive people with Bio-Alcamid implants. As a result, several plastic surgery societies now discourage the use of Bio-Alcamid and other permanent implants. For further information about this issue, see this CATIE News story.
Canadian infectious disease specialist Dr. Mona Loufty has conducted studies of different facial fillers in HIV-positive people. Her long-term results show that while most people are satisfied with facial implants, satisfaction rates with Bio-Alcamid seem to be somewhat lower than with PLA.
Dr. Loufty and colleagues have confirmed that the use of Bio-Alcamid in some people can be associated with complications over the long term. After an average of three years after implantation about 25% of participants were affected. This figure includes people with both confirmed and suspected infections in the face. Consequences of the infections included inflammation and lumps or nodules. In some cases, these infections were troublesome and required prolonged antibiotic therapy and surgery. The study team found that all participants with confirmed infections had prior dental procedures. These procedures, including routine dental cleaning, may have damaged or contaminated the Bio-Alcamid implants with bacteria, leading to infections.
Advice for dentists from doctors
Dr. Loufty and colleagues at Toronto’s Maple Leaf Medical Clinic encourage dentists caring for HIV-positive patients with Bio-Alcamid implants to first give them a broad-spectrum antibiotic one hour prior to dental procedures, including routine cleaning. Recommended antibiotics include the following:
- amoxicillin + clavulanic acid
These drugs are all chemically related to penicillin. In cases of penicillin allergy, Dr. Loufty and colleagues suggest that the antibiotic clindamycin may be used.
Additionally, Dr. Loufty and colleagues caution dentists that patients with Bio-Alcamid implants should not receive injections into “the upper gums leading into the cheek area, as it can puncture [the Bio-Alcamid implant] and lead to infection.”
The doctors also discourage X-ray exposure of the cheeks because X-rays can damage Bio-Alcamid; such X-rays are often done after accidents. Low-energy X-rays, such as those routinely done in dental clinics to assess the health of teeth, do not affect Bio-Alcamid.
Advice for HIV-positive people
The findings from Dr. Loufty’s study underscore the need for HIV-positive people who have facial implants to always remind their oral health care professionals, including dentists, hygienists and surgeons, about the presence of such implants prior to receiving any oral care.
—Sean R. Hosein
- Loutfy MR, Brunetta J, Kovacs C, et al. Four-Year Follow-Up of Polyalkylimide Gel Use for the Treatment of HIV-Associated Lipoatrophy. HIV Clinical Trials. 2011 Nov-Dec;12(6):323-32.
- Loufty MR. Antibiotic prophylaxis for patients who have had Bio-Alcamid injections into their cheeks. Dear Dentist letter. 21 December 2011.