the main manifestations of the lipodystrophy ( ld ) syndrome in patients with normal serum cortisol levels are fat accumulation in the dorsocervical spine ( also known as buffalo hump ) , in the breasts , and in the abdomen or fat reduction in the face and in the limbs . these body changes are accompanied by dyslipidemia and hyperglycemia . however , there are only few reports of hyperlipidemia and lipodystrophy associated with haart without pi [ 2 , 3 ] . a recent study by smith et al .   demonstrated an excess of cardiovascular risk factors in hiv patients receiving haart , and lipodystrophy syndrome has been considered a worrisome factor . this study was performed to analyze the body composition and metabolic variations in hiv-1 infected individuals during treatment with haart of different art regimen and without haart in the north - eastern part of india . a hospital based cross - sectional study conducted from october 2011 to september 2013 included random 101 seropositive hiv-1 male patients aged more than 15  years who are attending medicine out - patient department ( opd ) and art centre , centre of excellence , regional institute of medical sciences , for routine check - up on opd basis . these patients were categorised into the following groups : art nave patients ( n = 22 ) , hiv patients on zidovudine based regimen ( azt and 3tc and nvp or efv , n = 22 ) , stavudine based regimen ( d4 t and 3tc and nvp or efv , n = 18 ) , tenofovir based regimen ( tdf and 3tc and nvp or efv , n = 15 ) , and protease inhibitors based regimen ( atazanavir 300  mg boosted with low dose ritonavir 100  mg , n = 24 ) . the art was given to patients according to national aids control organization ( naco ) guidelines , india . patients who were known case of diabetes mellitus , chronic kidney disease , congestive cardiac failure , already on hypolipidemic drugs before starting art , and suffering from tuberculosis and other active opportunistic infections were excluded from the study . detailed history regarding clinicoepidemiological data including , facial dysmorphism ( lipoatrophy of face ) , exposure , hiv infection duration , duration of the present regimen , alcoholism ( > 80  gms / day ) , and cigarette smoking ( > 5  cigarettes / day ) were recorded in a preformed pro forma . anthropometric measurements , like body mass index ( bmi ) and waist - hip ratio , were measured . waist circumference was measured at midpoint between lowermost palpable rib and topmost point of iliac crest along midaxillary line , and hip circumference was measured at widest portion of buttocks . waist - hip ratio > 0.9 indicates truncal obesity and high risk for cardiovascular complications . total body water ( in percentage ) , bone mass ( in kgs ) , visceral fat ( in kgs ) , body fat ( in percentage ) , and muscle mass ( in kgs ) were analysed using tanita machine , a body composition guide for inner scan manufactured by tanita india private limited , mumbai . visceral fat ranging from 1 to 12  kgs was considered as healthy range and more than 12 as excess . blood biochemistry including lipid profile , kidney function test , and blood sugar levels ( random , fasting and postprandial ) was performed . anova and post hoc dunnet 's t3 test were used to determine significant difference among study population . the age range of study population was art nave patients , 24 to 51  years ; zidovudine based patients , 26 to 53  years ; stavudine based patients , 32 to 52  years ; tenofovir based patients , 37 to 60   years ; and protease inhibitors patients , 32 to 60  years . the mean duration of hiv infection and the present art regimen ( in months ) is shown in table 1 . lipoatrophy of face was most prevalent in hiv - positive population who are on stavudine based regimen ( 15 out of 18 patients , 83.3% ) and protease inhibitors based regimen ( 20 out of 24 patients , 83.3% ) . three patients ( 13.6% ) on zidovudine based regimen and 3 patients ( 20.0% ) on tenofovir based regimen had lipoatrophy of face ( refer table 2 ) . mean bmi of different categories of study population were in normal range , and there was no significant difference in mean bmi among different categories of study population ( p = 0.917 ) . among study population , excess visceral fat was most prevalent in protease inhibitors group ( 4 out of 24 patients , 16.7% ) . the mean total visceral fat among study population was in healthy range , and there was statistically insignificant difference among study population . though statistically insignificant , mean difference of total visceral fat between pis ( 6.21  4.79 ) and art nave ( 4.09  3.66 ) patients was about 2.11 . mean body fat percentage was in normal range among study population and did not vary significantly among different study groups ( p = 0.172 ) . the mean total body water percentage was relatively higher in zidovudine based regimen ( 61.98  7.86 ) and stavudine based regimen ( 61.4  6.63 ) than other groups ( art nave regimen was 59.80  9.73 , tenofovir based regimen was 58.90  4.9 , and protease inhibitors regimen was 57.64  6.99 ) , and there was no significant difference among study population ( p = 0.318 ) . there was no statistically significant difference among study population in terms of mean bone mass ( p = 0.200 ) and mean muscle mass ( p = 0.070 ) . waist - hip ratio ( mean ) in protease inhibitors group was 0.91  0.04 , indicating central obesity . the mean waist - hip ratio significantly varied among study population , being higher in hiv patients receiving protease inhibitors ( p = 0.001 ) . hypertriglyceridemia was found in stavudine ( 173.06  48.11 ) , tenofovir ( 164.07  77.40 ) , and protease inhibitors ( 249.83  125.3 ) based regimens . low hdl was found in zidovudine ( 32.75  7.19 ) , stavudine ( 26.72  7.12 ) , and protease inhibitors ( 32.79  11.0 ) based regimens . patients with protease inhibitors were found to have both fasting ( 118.04  46.03 ) and postprandial ( 205.38  105.26 ) hyperglycemia . there was a significant difference in total cholesterol ( p = 0.001 ) , triglycerides ( p = 0.000 ) , hdl ( p = 0.003 ) , ldl ( p = 0.009 ) , vldl ( p = 0.001 ) , rbs ( p = 0.000 ) , fbs ( p = 0.001 ) , and ppbs ( p = 0.000 ) among study population . the present study is a cross - sectional comparative data regarding body composition and metabolic parameters derangements among hiv patients receiving protease inhibitors and nrtis . 83.3% patients receiving protease inhibitors had facial dysmorphism in form of lipoatrophy and 16.7% patients had excess visceral fat with normal total body fat percentage . in addition to this , there was increased waist - hip ratio , more than 0.90 , indicating truncal obesity . there were also metabolic abnormalities in the form of hypertriglyceridemia , low hdl , high vldl , and fasting and postprandial hyperglycemia . these features indicate regional fat redistribution from periphery to visceral resulting in insulin resistance rather than mere fat loss or fat gain . similar finding was also described by previous study by dinges et al .   and carr et al . . analysed the paired data in hiv infected patients before and after initiating pis ( n = 20 ) . they also found significant increase in glucose ( + 9  3  mg / dl , p = 0.0136 ) , insulin ( + 12  4.9  mg / dl , p = 0.023 ) , triglycerides ( + 53  17  mg / dl , p = 0.0069 ) , and total and ldl cholesterol ( + 32  11  mg / dl and + 18  5  mg / dl , p = 0.0082 and 0.0026 , resp . ) . in present study , there was no significant difference between the study groups in terms of bmi , total body water , bone mass and muscle mass , and visceral and body fat . 788 cohorts of hiv patients on haart noticed 14% prevalence of metabolic syndrome according to international diabetic federation criteria and 18% prevalence of the same , according to us national cholesterol education program adult treatment panel iii ( atp iii ) criteria , in patients receiving pis , the highest being in indinavir and the least in amprenavir . 49% of patients had at least 2 features of metabolic syndrome but did not meet the diagnostic criteria . in present study also , it is emphasising the same fact of insulin resistance in the form of truncal adiposity and hyperglycemia in patients receiving pis . studied 148 hiv-1 patients ( 116 patients were on protease inhibitors and 32 had never taken protease inhibitors ) and in 47 healthy men found that development of syndromic features like central adiposity along with hypertriglyceridemia , hypercholesterolemia , and insulin resistance with type 2 diabetes mellitus occurred mainly with the use of all potent protease inhibitors and hence concluded it to be a class effect . current data suggests that abnormal fat distribution occurs in hiv patients receiving non - pis based regimen . peripheral fat wasting was noticed in clinically stable asymptomatic hiv patients and may be due to long term use of nrtis especially stavudine . lipoatrophy of face ( buccal pad fat atrophy ) was observed in 83.3% of patients receiving stavudine based haart , 13.6% of patients in zidovudine group , 20.0% of patients on tenofovir group , and none in art nave group . along with this , stavudine subgroup also had hypertriglyceridemia , low hdl , and postprandial hyperglycemia , which were almost absent in other nrtis groups . on the contrary , hypertriglyceridemia was also found in the tenofovir group . saint - marc et al .   in their cross - sectional data on 43 hiv patients on nrti found peripheral lipodystrophy ( bichat atrophy ) in 17 patients ( 63% ) receiving stavudine , 3 patients ( 18.75% ) receiving zidovudine and none in art nave . along with lipodystrophy , patients on stavudine had hypertriglyceridiemia which is similar to result of the present study . domingo et al . , in his study involving 150 hiv patients receiving haart , 75 stavudine based patients , and 75 zidovudine based patients noticed significant lower body fat in patients taking stavudine . analysed regional fat measured by dual energy x - ray absorptiometry ( dexa ) in 161 hiv patients and found progressive subcutaneous fat wasting occurring in stavudine - containing regimens compared with zidovudine - containing regimens ( relative risk was 1.085 per month ; p < 0.0001 ) and concluded that nrtis especially stavudine do have an independent contribution to fat wasting . other body composition parameters like total body water , muscle mass , and bone mass are not significantly affected among study population . hdl was significantly low in art nave and all nrti groups except for tenofovir group . though ldl was in normal range , it differed significantly ( p = 0.009 ) among study population , being high in stavudine based regimen ( 94.11  12.4 ) and protease inhibitors ( 98.3  27.8 ) .