Treatment of dyslipidaemia in HIV-infected persons

Accumulating evidence suggests that HIV-infected individuals have an increased risk of cardiovascular events. This risk seems to be at least partially mediated by dyslipidaemia, which is related to the use of highly active antiretroviral therapy (HAART). As HIV-infected individuals live longer due to HAART, their cardiovascular risk will invariably increase. Because HAART is likely to be used indefinitely, HAART-related dyslipidaemia has emerged as a major cardiovascular concern. This article summarises the evaluation of dyslipidaemia and cardiovascular risk in HIV-infected individuals, the potential pathophysiological and genetic mechanisms involved in HAART-related dyslipidaemia and the current treatment approaches. In general, dyslipidaemia is evaluated and treated as in HIV-negative persons. The first step is cardiovascular risk assessment and the determination of target lipid levels. A healthier lifestyle and, in particular, smoking cessation should be promoted. Lowering levels of low-density lipoprotein cholesterol (or, in the setting of significant hypertriglyceridaemia, non-high-density lipoprotein cholesterol) is the primary target of intervention. Switching HAART to a more lipid-favourable regimen should be considered if this does not jeopardise virological control. Many patients will need lipid-lowering drug therapy. Appropriate low-density lipoprotein cholesterol target levels may be more difficult to reach than in the HIV-negative population, and the potential for drug interactions when using lipid-lowering agents together with HAART needs to be considered. The identification of HAART strategies with no or minimal metabolic toxicity, and the identification of the safest and most efficacious lipid-lowering therapies for HIV-infected individuals with dyslipidaemia are important research goals.

Progressive neuropsychiatric problems following institution of highly active antiretroviral therapy

A 31 year old HIV infected woman developed neuropsychiatric problems soon after starting highly active antiretroviral therapy (HAART). Despite modifying and subsequently stopping HAART her condition progressively worsened. Cranial magnetic resonance imaging revealed multiple areas of abnormal signal suggestive of either a vasculitis or demyelination.

Acanthosis nigricans as an adverse effect of highly active antiretroviral therapy in an adolescent girl with human immunodeficiency virus infection

We report an 11-year-old girl with acanthosis nigricans that appeared after 4 years of treatment with didanosine, stavudine and amprenavir. Laboratory studies showed hyperglycemia, hyperinsulinemia and hypertriglyceridemia. Withdrawal of amprenavir resulted in disappearance of acanthosis nigricans and improvement of metabolic abnormalities.

Severe dyshidrosis in two patients with HIV infection shortly after starting highly active antiretroviral treatment

The use of highly active antiretroviral therapy (HAART) is the gold-standard treatment for HIV infected patients. We here describe two HIV positive patients whose histories are suggestive for dyshidrosis as an immune reconstitution inflammatory syndrome (IRIS). Several factors have been associated with the exacerbation of dyshidrosis lesions but no direct relationship with HAART has been reported until now.

Raised intracranial pressure complicating cryptococcal meningitis: immune reconstitution inflammatory syndrome or recurrent cryptococcal disease?

We report the case of a patient with advanced HIV disease and cryptococcal meningitis, who after an initially good clinical and mycological response to systemic anti-fungal treatment developed symptomatic raised intracranial pressure 10 days after initiation of highly active anti-retroviral therapy. We describe the subsequent clinical management and the features that suggest that this persistently raised ICP was more likely due to an immune reconstitution syndrome (IRIS) following HAART rather than relapse of cryptococcal disease or failure of anti-fungal therapy.

Transgenic expression of the deoxynucleotide carrier causes mitochondrial damage that is enhanced by NRTIs for AIDS

Nucleoside reverse transcriptase inhibitors (NRTIs) are antiretrovirals for AIDS with limiting mitochondrial side effects. The mitochondrial deoxynucleotide carrier (DNC) transports phosphorylated nucleosides for mitochondrial DNA replication and can transport phosphorylated NRTIs into mitochondria. Transgenic mice (TG) that exclusively overexpress DNC in the heart tested DNC's role in mitochondrial dysfunction from NRTIs. Two TG lines were created that overexpressed the human DNC gene in murine myocardium. Cardiac and mitochondrial structure and function were examined by magnetic resonance imaging, echocardiography, electrocardiography, transmission electron microscopy, and plasma lactate. Antiretroviral combinations (HAART) that contained NRTIs (stavudine (2', 3'-didehydro-2', 3'-deoxythymidine or d4T)/lamivudine/indinavir; or zidovudine (3' azido-3'-deoxythymidine or AZT)/lamivudine/indinavir; 35 days) were administered to simulate AIDS therapy. In parallel, a HAART combination without NRTIs (nevirapine/efavirenz/indinavir; 35 days) served as an NRTI-sparing, control regimen. Untreated DNC TGs exhibited normal cardiac function but abnormal mitochondrial ultrastructure. HAART that contained NRTIs caused cardiomyopathy in TGs with increased left ventricle mass and volume, heart rate variability, and worse mitochondrial ultrastructural defects. In contrast, treatment with an NRTI-sparing HAART regimen caused no cardiac changes. Data suggest the DNC is integral to mitochondrial homeostasis in vivo and may relate mechanistically to mitochondrial dysfunction in patients treated with HAART regimens that contain NRTIs.

Short communication: HIV infection, antiretrovirals, and apoptosis: studies on skeletal muscle

Increased apoptosis in CD4+ T lymphocytes plays an important role in the pathogenesis of HIV infection and it has also invoked some HIV-related as well as antiretroviral-related adverse events. We assessed whether increased apoptosis is also present in the skeletal muscle of HIV-infected patients. We included 36 consecutive individuals, 18 without (group A) and 18 with HIV infection. The latter group consisted of five asymptomatic antiretroviral-naive HIV-infected individuals (group B), six asymptomatic HIV-infected individuals on highly active antiretroviral therapy (HAART, group C), and seven HIV-infected individuals on HAART with lipodystrophy (group D). Immunohistochemical reaction using deoxyribonucleotidyltransferase-mediated- dUTP-biotin nick-end labeling (TUNEL) was performed on skeletal muscle samples. None of the uninfected patients (group A) showed data of increased apoptosis, while 16 out of 18 infected patients did (p < 0.001). All subgroups of infected subjects (groups B-D) showed a significant increase of apoptosis in TUNEL with respect to uninfected individuals, but the comparison between the different subgroups of infected patients did not reveal significant differences. We conclude that skeletal muscle of HIV-infected patients exhibits increased apoptosis compared with that of uninfected patients, but the role of HAART in inducing apoptosis remains to be established.

When to initiate antiretroviral therapy in HIV-1-infected adults: a review for clinicians and patients

One of the most controversial topics in the medical management of HIV disease is the optimal time to initiate highly active antiretroviral therapy (HAART) in HIV-1-infected adults. Premature exposure to antiretrovirals may precipitate early evolution of resistance and unnecessary side-effects, whereas remaining off HAART until late in the course of HIV disease may lead to reduced therapeutic benefits and elevated mortality. The lack of a randomised clinical trial to consider this issue has resulted in ongoing revision of expert recommendations and substantial variability between international consensus guidelines regarding the optimal time to initiate therapy. Since this uncertainty is a source of unease for both patients and clinicians, we summarise the latest evidence regarding the optimal time to initiate HAART with consideration of the potential benefits and drawbacks of starting HIV treatment at the different levels presently recommended in leading consensus guidelines.

Treatment of HIV-1-associated Kaposi's sarcoma with pegylated liposomal doxorubicin and HAART simultaneously induces effective tumor remission and CD4+ T cell recovery

BACKGROUND

The combination of highly active antiretroviral therapy (HAART) and liposomal doxorubicin is a promising approach for the treatment of progressive HIV-related Kaposi's sarcoma (KS). Here, we determined the safety, tolerability, and efficacy of liposomal doxorubicin and HAART as a combined treatment approach for advanced KS, and assessed the impact of liposomal doxorubicin on HAART-mediated immune reconstitution and viral suppression.

PATIENTS AND METHODS

In an uncontrolled observational trial, KS treatment responses were assessed in 54 HIV-1-infected patients with advanced KS according to ACTG criteria. Immunological and virological treatment responses were compared to 54 non-KS-affected HIV-1 patients who were individually matched to the study participants according to sex, age (+/- 5 years), CD4+ T cell count (+/- 25%), HIV RNA load (+/- 25%) and previous antiretroviral therapy exposure.

RESULTS

In 81.5% of the study patients, complete or partial responses were observed within a median of 8 weeks. Treatment-related side effects were predominantly confined to leukopenia (44.4% of patients) and mild-to-moderate liver enzyme elevation (22.3% of patients). Relative CD4+ T cell counts increased to a similar degree both in study patients and matched pairs (7% vs 6%, respectively), yet, absolute CD4+ T cell counts augmented considerably stronger in chemotherapy-naive matched pairs than in the study patients.

CONCLUSION

The simultaneous administration of HAART and liposomal doxorubicin is a safe and effective treatment approach for advanced KS and HAART-mediated recovery of relative CD4+ T cell counts does not seem to be impaired by concomitant treatment with liposomal doxorubicin.

Incidence and risk factors for liver enzyme elevation during highly active antiretroviral therapy in HIV-HCV co-infected patients: results from the Italian EPOKA-MASTER Cohort

BACKGROUND

The risk of hepatotoxicity associated with different highly active antiretroviral therapy (HAART) regimens (containing multiple-protease inhibitors, single-protease inhibitors or non nucleoside reverse transcriptase inhibitors) in HIV-HCV co-infected patients has not been fully assessed.

METHODS

Retrospective analysis of a prospective cohort of 1,038 HIV-HCV co-infected patients who commenced a new HAART in the Italian MASTER database. Patients were stratified into naïve and experienced to antiretroviral therapy before starting the study regimens. Time to grade > or =III hepatotoxicity (as by ACTG classification) was the primary outcome. Secondary outcome was time to grade IV hepatotoxicity.

RESULTS

Incidence of grade > or =III hepatotoxicity was 17.71 per 100 patient-years (p-yr) of follow up in naïve patient group and 8.22 per 100 p-yrs in experienced group (grade IV: 4.13 per 100 p-yrs and 1.08 per 100 p-yrs, respectively). In the latter group, the only independent factors associated with shorter time to the event at proportional hazards regression model were: previous liver transaminase elevations to grade > or =III, higher baseline alanine amino-transferase values, and use of a non nucleoside reverse transcriptase inhibitor based regimen. In the naive group, baseline aspartate transaminase level was associated with the primary outcome.

CONCLUSION

Use of a single or multiple protease inhibitor based regimen was not associated with risk of hepatotoxicity in either naïve or experienced patient groups to a statistically significant extent. A cautious approach with strict monitoring should be applied in HIV-HCV co-infected experienced patients with previous liver transaminase elevations, higher baseline alanine amino-transferase values and who receive regimens containing non nucleoside reverse transcriptase inhibitors.

High-risk dysmetabolism disorders associated with HAART-treated HIV disease, and reimbursement of lipid-lowering drugs, in a clinical and a socio-economic perspective

The significant advances achieved in the management of HIV disease, thanks to highly active antiretroviral therapy, are at risk of being frustrated by the recent changes in the cost reimbursement rules for all lipid-lowering drugs available in Italy. Unfortunately, the remarkably increased life expectancy achieved since mid-1996 by HIV-infected persons after the introduction of protease inhibitors and combined anti-HIV treatment, is accompanied by significant risks of developing diet-uncontrolled hypercholesterolemia and/or hypertriglyceridemia, often concurrent with insulin resistance, visceral adiposity, and hypertension, all known factors which can strongly predispose to severe cardiovascular events. International and national health care system recommendations regarding the reimbursability of lipid-lowering drugs have to take into careful consideration of this "special" category of patients (HIV-infected ones). These patients are exposed to a very frequent and severe, drug-induced dyslipidemia, and a subsequently elevated and progressively increasing cardiovascular risk, despite their proportionally lower mean age compared with that of the general at-risk population, and the lack of many concurrent risk factors which are employed to calculate the strict need for a lipid-lowering therapy, and its consequent cost reimbursement by the different health care systems.

Low frequency of renal function impairment during one-year of therapy with tenofovir-containing regimens in the real-world: a case-control study

Concern exists about the risk of nephrotoxicity using tenofovir (TDF) in HIV-infected patients. We performed a retrospective case-control study including 122 consecutive TDF-naive patients who started treatment with TDF-containing regimens and 194 patients receiving antiretroviral therapy with other antiretroviral drugs. During a 12-month observation period 5 (4.1%) patients in the TDF group versus 1 (0.5%) in the control group developed grade 1 or higher serum creatinine elevations (p = 0.018). Only 2 (1.6%) patients discontinued TDF treatment as a result of serum creatinine level elevations. In 4 of the 5 patients developing creatinine elevations TDF was combined with lopinavir-ritonavir. The use of TDF in clinical practice during a 12-month period is associated with low risk of mild renal failure. Further studies to assess long-term renal safety of this drug are needed.

Risk factors for CD4 lymphopenia in patients treated with a tenofovir/didanosine high dose-containing highly active antiretroviral therapy regimen

In this study, the dynamics of CD4 cell depletion during tenofovir/didanosine co-administration were analysed. Ninety-five HIV-positive patients were followed for 562 days, and 37 lost at least 50 CD4 cells, with a median delay of 274 days. Cox analysis showed that the CD4 cell decrease was associated with a duration of treatment by didanosine of more than 853 days and a didanosine dose of more than 5.50 mg/kg.

Substitution of nevirapine or efavirenz for protease inhibitor versus lipid-lowering therapy for the management of dyslipidaemia

OBJECTIVES

To evaluate simplified protease inhibitor (PI)-sparing antiretroviral treatment versus lipid-lowering therapy for the management of highly active antiretroviral therapy (HAART)-induced hyperlipidaemia.

DESIGN

Randomized, open-label clinical trial assessing the efficacy on hyperlipidaemia of a switching therapy from PI to non-nucleoside reverse transcriptase inhibitor (NNRTI) nevirapine or efavirenz versus a hypolipidaemic treatment (with pravastatin or bezafibrate) added to current, unchanged antiretroviral combination.

METHODS

All HIV-infected patients on their first HAART regimen, with stable immuno-virological features, naive to all NNRTIs, and with mixed hyperlipidaemia, were randomized to replace PI with nevirapine (arm A) or efavirenz (arm B), or to receive pravastatin (arm C) or bezafibrate (arm D) with unchanged HAART regimen, and were followed-up for 12 months.

RESULTS

One hundred and thirty patients were evaluated: 29 patients were randomized to arm A, 34 to arm B, 36 to arm C, and 31 to arm D. At the end of the 12-month follow-up, a reduction of 25.2, 9.4, 41.2 and 46.6% in mean triglyceridaemia versus respective baseline values was reported in groups A, B, C and D, respectively, with statistically significant difference between arms A-B and C-D (P < 0.01). Similar results were reported for total and low-density lipoprotein cholesterol levels. Viro-immunological efficacy and tolerability profile were comparable in all considered arms.

CONCLUSION

Pravastatin and bezafibrate proved significantly more effective in the management of HAART-related hyperlipidaemia than the switching therapy from PI to nevirapine or efavirenz.

Coinfection with HIV and Hepatitis C Virus in Injection Drug Users and Minority Populations

Coinfection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) is common. In the United States, it has been estimated that 25% of persons infected with HIV are also infected with HCV. The prevalence of coinfection with HIV and HCV is highest among those infected via percutaneous routes. In fact, in urban areas in the United States, 50%-90% of persons infected with HIV via injection drug use are coinfected with HCV. In addition, limited data from drug treatment centers in these urban areas suggest that the prevalence of coinfection with HIV and HCV may be highest among African Americans and Hispanics. Little information is available with regard to the epidemiology of coinfection with HIV and HCV among injection drug users (IDUs) or minority populations. Likewise, although there is a growing body of data on the potential complexities of treating HCV among IDUs and the poor response to current anti-HCV treatment among African Americans, few data address the therapy of coinfection with HIV and HCV among IDUs and minority populations.

Outcomes among Patients with End-Stage Liver Disease Who Are Coinfected with HIV and Hepatitis C Virus

In at-risk populations, shared routes of transmission lead to high rates of concordance between infection with human immunodeficiency virus (HIV) type 1 and hepatitis C virus (HCV). In the era of highly active antiretroviral therapy (HAART), end-stage liver disease (ESLD) has emerged as a leading cause of mortality in coinfected patients. HAART-related toxicities have been implicated, especially when given to patients with viral hepatitis. Rates of response to treatment for HCV infection in coinfected patients continue to lag behind those in monoinfected patients, even with the advent of pegylated interferons. Liver transplantation has been approached with caution in this population because of concern about the sequelae of immunosuppression and HAART-related hepatotoxicity, and results have been conflicting. Clinical and serological markers of ESLD in coinfected patients, management of cirrhosis, and the appropriateness of transplantation are discussed.

Incidence and risk factors of immune reconstitution inflammatory syndrome complicating HIV-associated cryptococcosis in France

BACKGROUND

Immune reconstitution inflammatory syndrome (IRIS) in association with cryptococcosis has been anecdotically reported following administration of highly active antiretroviral therapy (HAART).

OBJECTIVE

To analyse the incidence and risk factors for IRIS-associated cryptococcosis among HIV-infected patients.

DESIGN

Retrospective multicentre study between 1996 and 2000 through the French Cryptococcosis Database.

METHODS

Subsequent occurrence of IRIS examined in 120 HIV-infected adult patients treated with HAART and experiencing a first episode of culture-confirmed cryptococcosis.

RESULTS

Ten patients developed IRIS during the study period, giving an incidence of 10/239, or 4.2/100 person-years [95% confidence interval (CI), 2.2-7.8]. IRIS consisted of acute symptoms consistent with inflammation occurring within a median of 8 months (range, 2-37) after the diagnosis of cryptococcosis in the context of negative cultures and immunological and/or virological response to HAART. Radiology and histopathology detected features compatible with inflammation. Symptom severity required transfer into intensive care units for three patients and use of anti-inflammatory drugs for four. Three patients with evolutive IRIS died. Compared with patients without IRIS for whom complete clinical and microbiological information were available at baseline, previously unknown HIV infection [odds ratio (OR), 4.8; 95% CI, 1.0-21.7], CD4 cell count < 7 x 10 cells/l (OR, 4.0; 95% CI, 0.9-17.2), fungaemia (OR, 6.1; 95% CI, 1.1-35.2) and HAART initiation within 2 months of cryptococcosis diagnosis (OR, 5.50; 95% CI, 1.0-29.6) were independently associated with the risk of subsequent IRIS.

CONCLUSIONS

IRIS-related cryptococcosis was observed more frequently in severely immunocompromised patients with disseminated infection and HAART initiation soon after the diagnosis.

Clinical characteristics of IRIS syndrome in patients with HIV and tuberculosis

BACKGROUND

Some patients with HIV/tuberculosis (TB) coinfection who are on anti-TB treatment and highly active antiretroviral therapy (HAART) will develop an exacerbation of symptoms, signs or radiological manifestations of TB that are not due to relapse or recurrence of their TB. The aetiology of these immune reconstitution inflammatory syndrome (IRIS) reactions is unknown but it is presumed that they occur, at least in part, as a consequence of HAART-related reconstitution of immunity.

METHODS

Patients who were diagnosed with their first episode of definitive or presumed TB between January 2001 and July 2003 were identified from the Chelsea and Westminster TB/HIV database. The patients were classified into those who developed IRIS and those who did not using a set definition of the syndrome. Demographic, clinical and laboratory data relating to both HIV and TB were compared between the two groups.

RESULTS

A total of 55 cases of TB were identified, of which 45 cases were confirmed on culture or gene probe and 10 were presumed cases. Fourteen cases (25.5%) developed IRIS with a median (range) duration of 2.53 (0.53-14.97) months. The median baseline CD4 [interquartile range (IQR)] for the IRIS group was significantly lower at 80 (33-117) cells/mm3 (P = 0.05) than the non-IRIS group at 139 (77-284) cells/mm3. A significantly greater proportion of patients in the IRIS group [11/14 (78.60%), P = 0.011] had baseline CD4 < 100cells/mm3 compared with the non-IRIS group [16/41 (39.0%)]. There was no significant difference between the two groups when comparing the log10 baseline viral load (VL). Eight (57.0%) patients in the IRIS group had disseminated TB at baseline compared with seven (17.0%) in the non-IRIS group (P = 0.006). In those who had a detectable VL at baseline, the median fold change (IQR) in CD4 from baseline to 3 months was significantly higher in the IRIS group patients, 1.5 (0.6-5.6), compared with 0.7 (-0.2 to 1.0) for those in the non-IRIS group (P = 0.046).

CONCLUSIONS

Patients who develop IRIS are more likely to present with disseminated TB, have a CD4 count < 100 cells/mm3 and have a prompt rise in CD4 count in the initial 3 months of HAART.

Coronary artery calcium in HIV-infected men treated with highly active antiretroviral therapy

Calcium is a common component of an atherosclerotic plaque; therefore, the presence of coronary artery calcium (CAC) indicates atherosclerosis. This study investigated the difference in total CAC scores between HIV-infected patients treated with highly active antiretroviral therapy (HAART) and HIV-negative age-matched controls. HIV patients were 27 men treated with a protease inhibitor-containing HAART regimen for more than 1 year (M = 4.92 years, SD = 2.02), aged 30 to 60 years (M = 43.52 years, SD = 6.65), and not receiving lipid-lowering or hypoglycemic drugs. Controls were age-matched men randomly selected (three controls to one case, for a total of 81 controls) from our existing database of 25,250 men who self-referred for CAC screening (control database). Electron beam tomography was used to obtain CAC scores. The CAC scores were coded as above or below the age-specific (stratified in 5-year increments) 10th, 25th, 50th, 75th, or 90th percentile of our control database. Chi-square analyses for two independent samples indicated (1) a larger frequency of controls with CAC scores above the 10th (chi1= 8.32, P = .004) and 25th (chi1= 5.45, P = .02) percentiles than that of HIV patients, (2) no differences in CAC scores between groups above the 50th (chi = 0.85, P = .357) or 75th (chi = 0.46, P = .497) percentile, and (3) a larger frequency of HIV patients who were above the 90th percentile (chi = 4.5, P = .034). The strength of the relationship between group membership and scoring above the 90th percentile was significant (phi = 0.20, P = .034). These results tentatively suggest that there is an elevated level of subclinical atherosclerosis in HIV patients treated with HAART.

HIV, metabolic syndrome X, inflammation, oxidative stress, and coronary heart disease risk : role of protease inhibitor exposure

Differences on measures of metabolic syndrome X and coronary heart disease (CHD) risk, as well as potential pathophysiological mediators, inflammation, and oxidative stress, were examined as a function of HIV serostatus and highly active antiretroviral therapy (HAART) regimen with and without protease inhibitors (PIs). Data from 164 men and women, aged 18 to 55 yr, were used to compare 82 HIV+ subjects who were free of hepatitis C virus and were on a stable HAART regimen for >/=6 mo, with 82 seronegative subjects matched on age, sex, body mass index, and ethnicity. For the HIV+ subjects, after controlling for diabetes status and HIV disease progression, PI exposure was associated with greater oxidative stress, triglyceridemia, and lipidemia than it was for non-PI-exposed HIV+ subjects, and the risk of a future myocardial infarction was up to 56% greater in PI-exposed than in non-PI-exposed subjects and 129% greater than in controls. Although it is likely that the greatest proportion of CHD risk in the HIV+ subjects may be accounted for by pathological conditions linked to HIV infection in interaction with mediating processes such as inflammation, central obesity, and dyslipidemia, which was greater than in controls, it appears that PI medications may exacerbate oxidative stress and hypertriglyceridemia to enhance this risk.

Cardiovascular effects of HAART in infants and children of HIV-infected mothers

Over the past decade, the course of human immunodeficiency virus (HIV) infection has been markedly altered by highly active antiretroviral therapy (HAART). As advances in early diagnosis and aggressive therapy, as well as better supportive care, become available to more HIV-infected patients, survival is being prolonged and more patients are experiencing cardiac abnormalities. Cardiovascular manifestations of pediatric HIV infection have especially proven to be an ongoing challenge to practicing physicians, who face cardiac abnormalities ranging from asymptomatic cardiomyopathy to severe heart failure. Antiretroviral therapy has substantially decreased vertical transmission of HIV; however, studies of adults receiving HAART have found increased peripheral and coronary artery disease. Children exposed to this therapy in utero are thus at an increased risk for toxicity and cardiac abnormalities, regardless of their HIV status. Preliminary studies have reported complications including lactic acidosis and mitochondrial toxicity, as well as cardiomyopathy. Further studies are needed to explore the long-term effects and possible toxicities of prophylactic antiretroviral therapy on infants born to HIV-infected mothers.

Association between highly active antiretroviral therapy and hypertension in a large cohort of men followed from 1984 to 2003

OBJECTIVE

UO1-AI-35041: To examine the impact of HIV infection and highly active antiretroviral therapy on systolic and diastolic hypertension.

DESIGN

Cohort study with semi-annual assessment of the outcome.

METHODS

We studied 5578 participants of the Multicenter AIDS Cohort Study with blood pressure measurements obtained between 1984 and 2003. The primary outcomes were systolic hypertension (SH; systolic blood pressure > 140 mmHg) and diastolic hypertension (DH; diastolic blood pressure > 90 mmHg). Statistical analyses were performed using multiple logistic regression with robust variance estimation.

RESULTS

Of the 84 813 person-visits available for analysis, 7.3 and 8.0% showed SH and DH, respectively. Controlling for age, race, body mass index, and smoking, HIV positive men not taking antiretroviral therapy were significantly less likely than HIV negative men to have SH [odds ratio (OR), 0.79; 95% confidence interval (CI), 0.70-0.89], as were men taking mono/combination therapy (OR, 0.69; 95% CI, 0.59-0.80). The prevalence of SH among men taking highly active antiretroviral therapy (HAART) for less than 2 years was similar to that among HIV negative men (OR, 1.06; 95% CI, 0.87-1.30), but was significantly higher thereafter; for 2 to 5 years of HAART (OR, 1.51; 95% CI, 1.25-1.82) and for more than 5 years of HAART (OR, 1.70; 95% CI, 1.34-2.16). In contrast, DH was not significantly higher among men with prolonged HAART use compared to that among HIV negative controls.

CONCLUSIONS

Prolonged HAART use was significantly associated with a higher prevalence of SH. This finding suggests that individuals taking HAART may be at increased risk of developing hypertension-related conditions and underscores the importance of blood pressure monitoring among these individuals.