Risk factors for coronary heart disease in patients treated for human immunodeficiency virus infection compared with the general population

Ischemic heart disease in HIV-infected and HIV-uninfected individuals: a population-based cohort study

BACKGROUND

There are concerns about highly active antiretroviral therapy (HAART) causing a progressive increase in the risk of ischemic heart disease. We examined this issue in a nationwide cohort study of patients with human immunodeficiency virus (HIV) infection and a population-based control group.

METHODS

We determined the rate of first hospitalization for ischemic heart disease in all Danish patients with HIV infection (3953 patients) from 1 January 1995 through 31 December 2004 and compared this rate with that for 373,856 subjects in a population-based control group. Data on first hospitalization for ischemic heart disease and comorbidity were obtained from the Danish National Hospital Registry for all study participants. We used Cox's regression to compute the hospitalization rate ratio as an estimate of relative risk, adjusting for comorbidity.

RESULTS

Although the difference was not statistically significant, patients with HIV infection who had not initiated HAART were slightly more likely to be hospitalized for the first time with ischemic heart disease than were control subjects (adjusted relative risk, 1.39; 95% confidence interval, 0.81-2.33). After HAART initiation, the risk increase became substantially higher (adjusted relative risk, 2.12; 95% confidence interval, 1.62-2.76), but the relative risk did not further increase in the initial 8 years of HAART.

CONCLUSIONS

Compared with the general population, HIV-infected patients receiving HAART have an increased risk of ischemic heart disease, but the relative risk is stable up to 8 years after treatment initiation.

Class of antiretroviral drugs and the risk of myocardial infarction

BACKGROUND

We have previously demonstrated an association between combination antiretroviral therapy and the risk of myocardial infarction. It is not clear whether this association differs according to the class of antiretroviral drugs. We conducted a study to investigate the association of cumulative exposure to protease inhibitors and nonnucleoside reverse-transcriptase inhibitors with the risk of myocardial infarction.

METHODS

We analyzed data collected through February 2005 from our prospective observational study of 23,437 patients infected with the human immunodeficiency virus. The incidence rates of myocardial infarction during the follow-up period were calculated, and the associations between myocardial infarction and exposure to protease inhibitors or nonnucleoside reverse-transcriptase inhibitors were determined.

RESULTS

Three hundred forty-five patients had a myocardial infarction during 94,469 person-years of observation. The incidence of myocardial infarction increased from 1.53 per 1000 person-years in those not exposed to protease inhibitors to 6.01 per 1000 person-years in those exposed to protease inhibitors for more than 6 years. After adjustment for exposure to the other drug class and established cardiovascular risk factors (excluding lipid levels), the relative rate of myocardial infarction per year of protease-inhibitor exposure was 1.16 (95% confidence interval [CI], 1.10 to 1.23), whereas the relative rate per year of exposure to nonnucleoside reverse-transcriptase inhibitors was 1.05 (95% CI, 0.98 to 1.13). Adjustment for serum lipid levels further reduced the effect of exposure to each drug class to 1.10 (95% CI, 1.04 to 1.18) and 1.00 (95% CI, 0.93 to 1.09), respectively.

CONCLUSIONS

Increased exposure to protease inhibitors is associated with an increased risk of myocardial infarction, which is partly explained by dyslipidemia. We found no evidence of such an association for nonnucleoside reverse-transcriptase inhibitors; however, the number of person-years of observation for exposure to this class of drug was less than that for exposure to protease inhibitors.

HAART and the heart: changes in coronary risk factors and implications for coronary risk in men starting antiretroviral therapy

OBJECTIVES

To estimate changes in coronary risk factors and their implications for coronary heart disease (CHD) rates in men starting highly active antiretroviral therapy (HAART).

METHODS

Men participating in the Swiss HIV Cohort Study with measurements of coronary risk factors both before and up to 3 years after starting HAART were identified. Fractional polynomial regression was used to graph associations between risk factors and time on HAART. Mean risk factor changes associated with starting HAART were estimated using multilevel models. A prognostic model was used to predict corresponding CHD rate ratios.

RESULTS

Of 556 eligible men, 259 (47%) started a nonnucleoside reverse transcriptase inhibitor (NNRTI) and 297 a protease inhibitor (PI) based regimen. Levels of most risk factors increased sharply during the first 3 months on HAART, then more slowly. Increases were greater with PI- than NNRTI-based HAART for total cholesterol (1.18 vs. 0.98 mmol L(-1)), systolic blood pressure (3.6 vs. 0 mmHg) and BMI (1.04 vs. 0.55 kg m(2)) but not HDL cholesterol (0.24 vs. 0.32 mmol L(-1)) or glucose (1.02 vs. 1.03 mmol L(-1)). Predicted CHD rate ratios were 1.40 (95% CI 1.13-1.75) and 1.17 (0.95-1.47) for PI- and NNRTI-based HAART respectively.

CONCLUSIONS

Coronary heart disease rates will increase in a majority of patients starting HAART: however the increases corresponding to typical changes in risk factors are relatively modest and could be offset by lifestyle changes.

Lung cancer in HIV infected patients: facts, questions and challenges

AIDS related mortality has fallen sharply in industrialised countries since 1996 following the introduction of highly active antiretroviral therapy. This has been accompanied by an increase in the proportion of deaths attributable to non-AIDS defining solid tumours, especially lung cancer. The risk of developing lung cancer seems to be higher in HIV infected subjects than in the general population of the same age, partly because the former tend more frequently to be smokers and, especially, intravenous drug users. The carcinogenic role of the antiretroviral nucleoside drugs and their interaction with smoking needs to be examined. Interestingly, there is no clear relationship between the degree of immunosuppression and the risk of lung cancer, so the reason for the increased risk is unknown. The mean age of HIV infected patients at the time of lung cancer diagnosis is 45 years and most are symptomatic. Lung cancer is diagnosed when locally advanced or metastatic (stage III-IV) in 75-90% of cases, similar to patients with unknown HIV status. Adenocarcinoma is the most frequent histological type. The prognosis is worse in HIV infected patients than in the general lung cancer population. Efficacy and toxicity data for chemotherapy and radiation therapy are few and imprecise. Surgery remains the treatment of choice for localised disease in patients with adequate pulmonary function and general good health, regardless of immune status. Prospective clinical trials are needed to define the optimal detection and treatment strategies for lung cancer in HIV infected patients.

Prevalencia de factores de riesgo cardiovascular en pacientes con infección por el VIH

INTRODUCTION

To determine the prevalence of cardiovascular risk factors in human immunodeficiency virus (HIV)-infected patients.

PATIENTS AND METHOD

A cross-sectional study was performed with HIV-infected patients aged 20 or over managed at the outpatient Infectious Disease Unit during 2003. Clinical and epidemiological characteristics of HIV infection and cardiovascular risk factors were evaluated.

RESULTS

The final 760 patients included in the study had a mean of 1.5 cardiovascular risk factors, with smoking being the most prevalent (66.8%; CI 95%: 63.4-70.2). The cardiovascular risk factor of age and gender was present in 26.4% (CI 95%: 23.3-29.7) of patients and family history of premature coronary heart disease in 14.3% (CI 95%: 11.8-16.9). The prevalence of hypertension and diabetes mellitus was 13.2% (CI 95%: 10.8-15.8) and 4.3% (CI 95%: 3.0-6.0), respectively. High density lipoprotein (HDL) cholesterol concentration under 40 mg/dl was found in 29.3% (CI 95%: 26.1-32.7) and above 60 mg/dl in 16.3% (CI 95%: 13.8-19.1). Twenty-five patients (3.3%; CI 95%: 2.1-4.8) had suffered overt cardiovascular disease.

CONCLUSION

Smoking and HDL cholesterol were the main cardiovascular risk factors in this HIV-infected cohort.

A Smoking Cessation Programme in HIV-Infected Individuals: A Pilot Study

Background

Antiretroviral therapy (ART) is a risk factor for cardiovascular disease (CVD) and smoking the most important modifiable cardiovascular risk factor.

Methods

We prospectively evaluated a smoking cessation programme (SCP) in HIV-infected individuals (intervention: counselling and nicotine replacement therapy). Primary endpoint was the smoking cessation rate at 12 months; secondary endpoints were CVD morbidity and mortality. Controls were a not randomized control group of smokers not participating in the SCP.

Results

Four-hundred and seventeen of 680 (61%) patients were smokers, and 34 of these participated in the SCP. Of these 34 individuals, 82% were male, the median age was 43 years, prior AIDS was recorded in 29%, and depressive disorder was recorded in 18%. Twenty-five (74%) patients were receiving ART. Additional risk factors were dyslipidaemia (68%), a prior cardiovascular event (24%), hypertension (15%), and a family history of CVD in 2/34 (6%) individuals. According to the Framingham equation, the 10-year risk of CVD was higher in SCP participants than in controls (11.2% versus 8.5%, P=0.06). At termination of the SCP, 17/34 (50%) individuals had stopped smoking compared with 57/383 (15%) controls. Self-reported smoking abstinence for ≥12 months was 13/34 (38%) in the intervention group and 27/383 (7%) in the control group (odds ration 6.2, 95% confidence interval 2.8–14.3). During the follow-up, two SCP participants and 4 controls experienced a myocardial infarction. One patient in the control group died of CVD.

Conclusions

SCP in HIV-infected individuals is feasible and should be encouraged. The long-term impact of smoking cessation on CVD morbidity and mortality should be evaluated in comparative trials.

[Risk factors in a young population with acute myocardial infarction: one year prospective study]

OBJECTIVE

The objective of this work is to give epidemiological data, established in a prospective way, on the myocardial infarction in young and its risk factors.

METHODS

All patients admitted to the CHG of Pau for myocardial infarction, old, for the men of less than 45 years and for the women of less than 55 years, of November the 1st 2002 to October 31st, 2003, are included.

RESULTS

Twenty-seven patients (11.2%) do a myocardial infarction including 44.4% women. The found traditional risk factors are: smoking (92.6%), absence of regular physical activity (81.5%), dyslipidaemia (66.7%), family history of cardiovascular disease (48.2%), hypertension (37.0%), obesity (18.5%), oral contraception (11.1%), diabetes (7.4%), personal thrombotic history (7.4%). The principal emergent risk factors highlighted are: stress (66.7%), inhibitor of the activation of the plasminogene (57.1%), C-reactive protein (50%), lipoprotein a (41.7%), fibrinogen (33.3%), elevated plasma homocysteine (25%), excessive alcohol use (22.2%). None patients does not have an absolute cardiovascular risk > 20%. The clinical characteristics, coronarographic data and the acute treatments were also listed. The prognosis is worse for the women with more risk factors, more complications, and risk of more significant ventricular replanning.

CONCLUSION

The principal risk factors of the myocardial infarction in young can be modifiable. The prevention is of primary importance. The therapeutic education of the patients corresponds to the total assumption of responsibility required by this pathology.

Risk factors for osteonecrosis in HIV-infected patients: impact of treatment with combination antiretroviral therapy

BACKGROUND

Osteonecrosis was increasingly associated with HIV infection in the 1990s. It is unclear whether its risk increases with the duration of HIV infection, the duration of combination antiretroviral therapy (cART) or both.

OBJECTIVE

To analyse factors associated with the rate of symptomatic osteonecrosis, particularly the relative impacts of the duration of HIV infection and the duration of cART, using the French Hospital Database on HIV, which comprises a large number of subjects with substantial follow-up.

METHODS

Poisson regression model was used to identify factors associated with the rate of osteonecrosis among patients enrolled in 1996-2002.

RESULTS

The study involved 56,393 subjects with a total follow-up of 229,031 person-years. Symptomatic osteonecrosis was diagnosed in 104 subjects with an incidence rate of 4.5/10,000 person-years. Multivariate analysis identified three factors associated with the rate of osteonecrosis: prior AIDS-defining illnesses [adjusted relative rate (RR), 3.1; 95% confidence interval (CI), 2.0-4.9], the CD4 cell nadir [RR, 1.6 (95% CI, 0.9-2.9) for CD4 cell count 50-199 cells/microl; RR, 1.8 (95% CI, 1.0-3.3) for CD4 cell count < 50 cells/microl; both relative to CD4 cell count > or = 200 cells/microl] and exposure to cART. Compared with unexposed patients, the RR of osteonecrosis ranged from 2.6 (95% CI, 1.2-5.9) in patients treated with cART for < 12 months to 5.1 (95% CI, 2.1-12.6) in patients treated for > or = 60 months.

CONCLUSIONS

Osteonecrosis appears to be a complication of both HIV infection and cART.

The use of the Framingham equation to predict myocardial infarctions in HIV-infected patients: comparison with observed events in the D:A:D Study

BACKGROUND

The D:A:D (Data Collection on Adverse Events of Anti-HIV Drugs) Study, a prospective observational study on a cohort of 23 468 patients with HIV infection, indicated that the incidence of myocardial infarction (MI) increased by 26% per year of exposure to combination antiretroviral treatment (CART). However, it remains unclear whether the observed increase in the rate of MI in this population can be attributed to changes in conventional cardiovascular risk factors.

OBJECTIVE

To compare the number of MIs observed among participants in the D:A:D Study with the number predicted by assuming that conventional cardiovascular risk equations apply to patients with HIV infection.

METHODS

The Framingham equation, a conventional cardiovascular risk algorithm, was applied to individual patient data in the D:A:D Study to predict rates of MI by duration of CART. A series of sensitivity analyses were performed to assess the effect of model and data assumptions. Predictions were extrapolated to provide 10-year risk estimates, and various scenarios were modelled to assess the expected effect of different interventions.

RESULTS

In patients receiving CART, the observed numbers of MIs during D:A:D follow up were similar to or somewhat higher than predicted numbers: 9 observed vs 5.5 events predicted, 14 vs 9.8, 22 vs 14.9, 31 vs 23.2 and 47 vs 37.0 for<1 year, 1-2 years, 2-3 years, 3-4 years and >4 years CART exposure, respectively. In patients who had not received CART, the observed number of MIs was fewer than predicted (3 observed vs 7.6 predicted). Nine per cent of the study population have a predicted 10-year risk of MI above 10%, a level usually associated with initiation of intervention on risk factors.

CONCLUSIONS

A consistent feature of all analyses was that observed and predicted rates of MI increased in a parallel fashion with increased CART duration, suggesting that the observed increase in risk of MI may at least in part be explained by CART-induced changes in conventional risk factors. These findings provide guidance in terms of choosing lifestyle or therapeutic interventions to decrease those risk factors in much the same way as in persons without HIV infection.

Antiretroviral medications associated with elevated blood pressure among patients receiving highly active antiretroviral therapy

OBJECTIVE

To examine the effect of antiretroviral agents and clinical factors on the development of elevated blood pressure (BP).

METHODS

Observational cohort study of patients initiating their first HAART regimen. We evaluated mean BP prior to HAART and while receiving HAART in relation to antiretroviral classes and individual agents, and demographic and clinical characteristics including change in body mass index (BMI) while on HAART. We used logistic regression analysis to examine factors associated with elevated BP [> or = 10 mmHg increase in systolic BP (SBP), diastolic BP (DBP) or new diagnosis of hypertension].

RESULTS

Among 444 patients who had 4592 BP readings, 95 patients developed elevated SBP (n = 83), elevated DBP (n = 33), or a new diagnosis of hypertension (n = 11) after initiating HAART. In multivariate analysis, patients on lopinavir/ritonavir had the highest risk of developing elevated BP [odds ratio (OR), 2.5; P = 0.03] compared with efavirenz-based regimens. When change in BMI was added to the model, increased BMI was significantly associated with elevated BP (OR, 1.3; P = 0.02), and the association between lopinavir/ritonavir and elevated BP was no longer present. Compared with lopinavir/ritonavir-based regimens, patients receiving atazanavir (OR, 0.2; P = 0.03), efavirenz (OR, 0.4; P = 0.02), nelfinavir (OR, 0.3; P = 0.02), or indinavir (OR, 0.3; P = 0.01) had significantly lower odds of developing elevated BP.

CONCLUSIONS

Treatment with lopinavir/ritonavir is significantly associated with elevated BP, an effect that appears to be mediated through an increase in BMI. Patients receiving atazanavir were least likely to develop elevated BP. The impact of antiretroviral medications on cardiovascular disease risk factors will increasingly influence treatment decisions.

Assessment of adipokine expression and mitochondrial toxicity in HIV patients with lipoatrophy on stavudine- and zidovudine-containing regimens

OBJECTIVES

Despite evidence for the role of adipokines such as adiponectin in the metabolic toxicities of protease inhibitor (PI)-treated patients, little is known about their role in nucleoside reverse transcriptase inhibitor (NRTI)-induced lipoatrophy (LA). We analyzed the relations between mitochondrial toxicity, adipokine expression, and clinical LA in peripheral blood mononuclear cells (PBMCs) and adipose samples from individuals treated with stavudine (d4T) or zidovudine (ZDV) in comparison to patients undergoing highly active antiretroviral therapy (HAART) as well as HIV-negative individuals.

METHODS

In this cross-sectional analysis, we studied 18 PI-naive HIV-infected patients with LA treated with d4T (d4T+LA+ [n = 12]) or zidovudine (ZDV+LA+ [n = 6]) in comparison to HAART-treated patients with (HAART+LA+ [n = 8]) and without (HAART+LA- [n = 8]) LA as well as HIV-negative controls (n = 12). Adipose samples were assessed for protein and/or messenger RNA (mRNA) levels of adiponectin, tumor necrosis factor-alpha (TNFalpha), interleukin (IL)-6, and sterol regulatory element-binding protein (SREBP) 1a/c in all groups, whereas adipose and PBMC samples from the d4T+LA+, ZDV+LA+, and HIV-negative subgroups were assessed for mitochondrial DNA (mtDNA) depletion and cytochrome c-oxidase (COX) II/COX IV ratios.

RESULTS

There was no change in mtDNA levels in adipose or PBMC samples in NRTI-treated patients with LA, although patients treated with d4T had reduced COX II/COX IV ratios in adipose and PBMC samples. Adipose tissue adiponectin mRNA and plasma levels were reduced in the d4T- and ZDV-treated patients regardless of the use of PIs. Tissue SREBP1c mRNA levels were also significantly reduced in both NRTI groups when compared with the HIV-negative controls. Significant reductions in SREBP1c levels were also evident with the HAART+LA+ group when compared with HAART+LA- controls.

CONCLUSIONS

Patients with LA on d4T-based regimens show evidence of mitochondrial respiratory chain dysfunction, whereas the d4T- and ZDV-based regimens also demonstrated reduced SREBP1c and adiponectin levels, findings that have previously been shown with PIs.

Tobacco use and readiness to quit smoking in low-income HIV-infected persons

The study aim was to identify covariates of smoking status and readiness to quit that encompassed key sociodemographic and health status variables, health-related quality of life, drug use and unprotected sex, and tobacco use variables in a cohort of low-income persons living with HIV. We also examined the impact of HIV diagnosis on smoking cessation. The sample (N = 428) was mostly male (59%) and Black (53%) or Hispanic (30%), and had a high school education or less (87%). Mean age was 40 years. Two-thirds of participants were current smokers, 19% former smokers, and 16% never smokers. Current smokers smoked a mean of 16 cigarettes/day for 22 years; 42% were in the precontemplation stage of readiness to quit smoking, 40% were contemplators, and 18% were in preparation. Most current smokers (81%) reported receiving medical advice to quit smoking. Multivariate logistic regression analyses indicated that current smokers, compared with former smokers, were more likely to use illicit drugs, perceive a lower health risk for continued smoking, and report less pain. Current smokers, compared with nonsmokers (former and never smokers), were more likely to report greater illicit drug use in their lifetime, current illicit drug use, and less pain. A multiple linear regression indicated that greater current illicit drug use, greater emotional distress, and a lower number of quit attempts were associated with lower stage of readiness to quit smoking. These findings confirm a high prevalence of smoking among HIV-infected persons and suggest a complex interplay among drug use, pain, and emotional distress that impact smoking status and, among smokers, readiness to quit. Tobacco control programs for HIV-infected persons should build motivation to quit smoking and address salient barriers to cessation--such as comorbid drug use, emotional distress, pain, and access to and coverage for treatment--and should educate smokers regarding the HIV-specific health benefits of cessation.

Lung cancer, a new challenge in the HIV-infected population

HIV infection predisposes patients to AIDS-defining malignancies, some of which, such as Kaposi's sarcoma and non-Hodgkin lymphoma, can affect the lungs. In 1996, AIDS-related mortality started to fall sharply in industrialized countries following the introduction of highly active antiretroviral treatments (HAART). This was accompanied by an increase in the proportion of deaths attributable to non AIDS-defining solid tumors, and especially lung cancer (LC). The increased risk of LC relative to the general population of the same age seems to be due partly to a higher prevalence of smoking among HIV-infected subjects. The average age of HIV-infected patients at LC diagnosis is about 45 years. Most patients are symptomatic at diagnosis and have only mild or moderate immunosuppression. LC is diagnosed when it is locally advanced or metastatic (stages III-IV) in 75-90% of cases, as in patients with unknown HIV serostatus. Adenocarcinoma is the most frequent histologic type. The prognosis of LC is poorer in HIV-infected patients than in the general population. Data on the efficacy and toxicity of chemotherapy in this setting are rare and rather imprecise. Surgery remains the reference treatment for localized disease in patients with adequate functional status and general health, regardless of their immune status. Prospective clinical trials are needed to define the optimal LC treatment strategies in HIV-infected patients.

[Adverse effects of antiretroviral treatments]

The efficacy of antiretroviral drugs has improved the prognosis for infection by human immunodeficiency virus (HIV); it is nonetheless accompanied by toxicity specific to these agents. Adverse effects of these treatments are a major cause of poor compliance as well as of the cessation or change of treatment. Knowledge of these effects allows physicians to choose an individualized and effective treatment for each patient, one that is well tolerated and appropriate to the patient's sometimes complex medical history. Although some of these adverse effects can be life-threatening (drug eruptions with nevirapine and abacavir, pancreatitis with didanosine, or lactic acidosis with nucleoside analogs), most are reversible. Lipodystrophies, sometimes combining morphologic and metabolic disorders, are observed in some patients after several years of treatment and appear to increase cardiovascular risk. They are one of the major disadvantages of combined treatments.

Predictors of Hypertension and Changes of Blood Pressure in HIV-Infected Patients

Objective

We assessed predictors of changes in systolic (SBP) and diastolic (DBP) blood pressure during follow-up and of the development of hypertension in HIV-infected individuals.

Methods

International cohort collaborative study (D:A:D) of established prospective cohorts of HIV-1-infected patients. Longitudinal analysis of changes in blood pressure (BP) was performed using mixed effects models in 17170 patients. Predictors of development of hypertension during follow-up (systolic BP ≥140 and/or diastolic BP ≥90 mmHg or initiation of antihypertensive treatment) were assessed using Cox models in 8 984 patients with a normal BP level at baseline.

Results

73548 BP measurements with a median of 4 per patient (interquartile range [IQR]: 2–6) were recorded over a median follow-up of 2.3 years (IQR: 1.5–2.6). Risk factors significantly associated with a development of higher systolic BP and diastolic BP (differences ≥5 mmHg and P-values <0.001) during follow-up were: older age, male sex, higher body mass index (BMI) and use of BP-lowering drugs. In patients with normal BP at baseline, 1186 developed hypertension for an incidence of 72.1 per 1000 person-years (95% confidence interval: 68.2–76.0). Factors associated with development of hypertension were: male sex, higher BMI, older age, higher BP at baseline, high total cholesterol and clinical lipodystrophy. Cumulative duration of exposure to nucleoside reverse transcriptase inhibitors ( P=0.75), protease inhibitors ( P=0.92) as well as type of antiretroviral treatment at baseline ( P=0.18) were not associated with a higher risk of hypertension. Cumulative duration of exposure to non-nucleoside reverse transcriptase inhibitors (NNRTIs) was significantly associated with lower risk of hypertension (hazard ratio=0.78 and 0.67 for those treated ≤10 months and >10 months compared with no exposure; P=0.005).

Conclusions

Increased blood pressure in HIV-infected individuals is associated with established risk factors for hypertension. There was no evidence for an independent deleterious effect of any class of antiretroviral drugs on BP, although the use of NNRTIs was associated with a lower risk of development of hypertension.

Non-AIDS-defining cancers and HIV infection

With fewer patients now succumbing to infectious complications of AIDS, other HIV-related morbidities, such as malignancies, have become increasingly important. Apart from Kaposi's sarcoma, non-Hodgkin's lymphoma, and cervical cancer, which are considered as AIDS-defining, several additional cancers, referred to as non-AIDS-defining cancers, are also statistically increased in HIV-infected persons. These include Hodgkin's disease, anal carcinoma, lung cancer, nonmelanomatous skin cancer, and testicular germ cell tumors, among others. However, the types of cancer observed at an increased frequency and the relative risks reported vary widely among studies. Although immunosuppression is consistently associated with an increased risk of AIDS-related malignancies, the role of immunosuppression in the pathogenesis of non-AIDS- defining cancers is controversial. Although data regarding the optimal management of these cancers are lacking, current studies suggest that patients with HIV-associated malignancies should be treated with similar approaches to those of their counterparts in the general population.

Aerodigestive cancers in HIV infection

PURPOSE OF REVIEW

Aerodigestive (lung, head and neck) cancers are among the most prevalent and deadly neoplasms worldwide, and the incidence rates are rising. Given the improvements in life expectancy of persons with HIV/AIDS when treated with highly active antiretroviral agents, persons with HIV infection are therefore increasingly likely to develop these malignancies. This chapter focuses on the epidemiology of these malignancies and reviews the most recent literature and current understanding of the causes and treatment of these malignancies in HIV-positive populations.

RECENT FINDINGS

Aerodigestive neoplasms in patients with HIV infection are associated with younger age at diagnosis, cigarette smoking, advanced stage at presentation, and a more aggressive clinical course. The causes of these cancers, aside from the traditional risk factors of tobacco and alcohol exposure, are not clear. Although these neoplasms are non-AIDS defining, factors that might contribute to risk include HIV-related immunosuppression and co-infection with high-risk human papillomavirus subtypes.

SUMMARY

With continued improvements in therapies for HIV, the expected increase in incidence and mortality of persons with HIV infection from aerodigestive malignancies will likely become a major public health concern. Given the younger age of HIV-infected patients with these malignancies and the apparently higher rates of smoking among HIV-positive individuals, aggressive smoking cessation efforts should be directed to this high-risk population.

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.

Increased cardiovascular disease risk indices in HIV-infected women

Little is known regarding cardiovascular disease risk indices in HIV-infected women. This study investigated cardiovascular disease risk indices in 100 consecutively recruited HIV-infected women and 75 healthy female control subjects. Subjects were recruited from hospital- and community-based health care providers. C-reactive protein (CRP), interleukin-6 (IL-6), adiponectin, lipid, and glucose levels were the main outcome measures. CT scan, dual-energy x-ray absorptiometry (DXA), and anthropometry were used to assess body composition. Although similar in age, weight, and racial composition, HIV-infected women demonstrated higher CRP (4.6 +/- 0.7 vs. 2.3 +/- 0.4 mg/L, P = 0.007), IL-6 (2.7 +/- 0.2 vs. 1.8 +/- 0.1 pg/mL, P = 0.02), triglyceride (1.84 +/- 0.21 vs. 0.85 +/- 0.05 mM, P = 0.0002), 2-hour glucose after oral glucose challenge (6.88 +/- 0.22 vs. 5.72 +/- 0.17 mM, P = 0.0003), and fasting insulin (81 +/- 8 vs. 45 +/- 2 pM, P = 0.0002) and lower high-density lipoprotein cholesterol (1.17 +/- 0.03 vs. 1.45 +/- 0.05 mM, P < 0.0001) and adiponectin (5.4 +/- 0.3 vs. 7.6 +/- 0.5 mg/L, P = 0.0001) levels compared with the control population. HIV-infected women had more abdominal visceral fat and less extremity fat by CT and DXA scan and demonstrated a higher waist-to-hip ratio (WHR) than the control population. Within the HIV group, CRP and other indices were significantly related to body composition in stepwise regression models. Among all subjects, WHR, but not HIV status, was significantly related to CRP and other cardiovascular disease risk indices. HIV-infected women demonstrate significantly increased risk factors for cardiovascular disease in association with abnormal fat distribution.

Non—AIDS–Defining cancers and HIV infection

With fewer patients now succumbing to infectious complications of AIDS, other HIV-related morbidities such as malignancies have become increasingly important. Apart from Kaposi's sarcoma, non-Hodgkin's lymphoma, and cervical cancer, which are considered as AIDS-defining, several additional cancers, referred to as non-AIDS-defining cancers, are also statistically increased in HIV-infected persons. These include Hodgkin's disease, anal carcinoma, lung cancer, nonmelanomatous skin cancer, and testicular germ cell tumors, among others. However, the types of cancer observed at an increased frequency and the relative risks reported vary widely among studies. Although immunosuppression is consistently associated with an increased risk of AIDS-related malignancies, the role of immunosuppression in the pathogenesis of non-AIDS- defining cancers is controversial. Although data regarding the optimal management of these cancers are lacking, current studies suggest that patients with HIV-associated malignancies should be treated with similar approaches to those of their counterparts in the general population.

Protease inhibitor exposure and increased risk of cardiovascular disease in HIV-infected patients

OBJECTIVES

To study the relationship between exposure to protease inhibitor (PI) therapy and increased risk of cardiovascular events in HIV-infected patients.

METHODS

We estimated the risk of cardiovascular disease (CVD) events with PI exposure in a cohort of HIV-infected patients using a time-dependent Cox proportional hazards model adjusting for the major CVD risk factors. Only the first CVD event for each subject was counted.

RESULTS

Of a total of 7542 patients, 77% were exposed to PIs. CVD event rates were 9.8/1000 and 6.5/1000 person-years of follow-up (PYFU) in the PI-exposed and nonexposed groups, respectively (P=0.0008). PI exposure >/=60 days was associated with an increased risk of CVD event [adjusted hazards ratio (HR(adj)) 1.71; 95% confidence interval (CI) 1.08-2.74; P=0.03]. Results from a subgroup of patients aged between 35 and 65 years were similar (HR(adj) 1.90; 95% CI 1.13-3.20; P=0.02). Other significant risk factors included smoking status, age, hypertension, diabetes mellitus and pre-existing CVD.

CONCLUSIONS

Patients exposed to PI therapy had an increased risk of CVD events. Clinicians should evaluate the risk of CVD when making treatment decisions for HIV-infected patients.

Interrupting highly active antiretroviral therapy in patients with HIV

Scheduled treatment interruptions are preplanned interruptions of antiretroviral treatment, which may be directed by time (e.g., cycles of 8 weeks on treatment and 8 weeks off treatment); the concentration of CD4+ lymphocytes (the CD4 count); HIV-1 RNA concentration (viral load); or other factors. This review covers the rationale of scheduled treatment interruptions and the different strategies that have been explored. It examines the issue of autovaccination, resistance and other risks and benefits. Scheduled-treatment-interruption studies in three populations are discussed: patients who initiated highly active antiretroviral therapy during acute HIV infection; patients with successfully treated chronic HIV infection; and patients with highly active antiretroviral therapy failure.

Sex and the course of HIV infection in the pre- and highly active antiretroviral therapy eras

We reviewed the available literature on the potential effects of sex on the course of HIV infection and found that there is little evidence for sex differences in the rate of disease progression in the pre-highly active antiretroviral therapy (HAART) and HAART era. Compared to men, women appeared to have lower HIV RNA levels and higher CD4 cell counts shortly after infection with HIV, but studies were inconclusive regarding whether these differences diminish over time. Differences in viral load or CD4+ cell count might cause women to delay initiation of HAART. Nonetheless, we found no substantial sex difference in the benefit of antiretroviral therapy. The studies we reviewed failed to find any harmful effect of pregnancy on HIV disease progression. With the availability of effective antiretroviral agents, HIV-infected women have increasingly decided to have children. Conflicting results exist on the effect of HAART on regression of cervical intra-epithelial neoplasia (CIN). Unlike CIN, invasive cervical cancer has not been found to be much higher in HIV-infected women than in HIV-uninfected women. Although publication bias cannot be ruled out, published studies suggest higher rates of adverse events among HIV-infected women on therapy as compared to men. As more pharmacological agents are developed, it is especially important that potential sex differences in pharmacodynamics are assessed. The relationship between metabolic abnormalities, changes in body habitus, and endocrine perturbations has not been extensively studied. Whether sex differences are due to unalterable genetic factors or social and environmental conditions, it is imperative that all HIV-infected individuals have equal access to interventions that can slow disease progression.

Metabolic syndrome among HIV-infected patients: prevalence, characteristics, and related factors

OBJECTIVE

To assess the prevalence in HIV-infected patients of the metabolic syndrome as defined by the National Cholesterol Education Program, i.e., three or more of the following components: abdominal obesity, hypertriglyceridemia, low HDL cholesterol, high blood pressure, and high fasting glucose.

RESEARCH DESIGN AND METHODS

In this cross-sectional study, 710 HIV-infected patients managed at the outpatient clinic of a tertiary hospital during 2003 completed the study protocol consisting of a medical examination and laboratory analysis after a 12-h overnight fast.

RESULTS

Metabolic syndrome prevalence was 17% and increased from 5.1% among HIV-infected patients under age 30 years to 27.0% for those aged 50-59 years. Age (per 10-year increment) (odds ratio [OR] 1.41 [95% CI 1.12-1.77]), BMI (1.27 [1.19-1.36]), past and present protease inhibitor exposure (2.96 [1.03-3.55] and 4.18 [1.4-12.5], respectively) were independently associated with the metabolic syndrome on logistic regression analysis. Furthermore, only stavudine (d4T) (1.74 [1.01-2.98]) and lopinavir/ritonavir (2.46 [1.28-4.71]) were associated with the metabolic syndrome after adjustment for age and BMI.

CONCLUSIONS

The prevalence of metabolic syndrome among these HIV-infected patients is similar to that previously reported in uninfected individuals. Of specific concern is the association of protease inhibitor exposure with the metabolic syndrome and, more specifically, with exposure to stavudine and lopinavir/ritonavir when individual antiretroviral drugs were analyzed.

Causes et caractéristiques des décès des patients infectés par le VIH-1, en succès immuno-virologique sous traitement antirétroviral

INTRODUCTION

To analyse the causes of death among HIV-infected adults in France in the year 2000.

METHODS

Based on data from a national survey, our study describes and analyses the causes and characteristics of patients with immunological and virological response (CD4>200/mm3, ARN-HIV<500 copies/mL), who died during antiretroviral treatment.

RESULTS

Among a total of 964 deaths registered, data on 864 cases were available for analysis. One hundred forty-nine patients (17%)were immunovirological responders. The underlying causes of death were non AIDS-defining malignancies for 36 (24%), mainly due to lung cancer (16 cases), hepatocarcinoma (7) and ano-rectal carcinoma (3), AIDS for 22 (15%), mainly due to Non Hodgkin Lymphoma (10 cases) and uterine cancer (3), cardiovascular diseases for 22 (15%), post hepatitis C hepatic failure for 16 (11%), suicide for 16 (11%), and bacterial infections for 14(9%). When comparing characteristics of death in the 149 responders versus the 715 other patients, the responders were significantly more frequently: co-infected by HCV+ (45 vs. 33%), injected drug addicts (40 vs. 27%),alcoholics (38 vs. 28 %), and dyslipidemics (19 vs. 11%). In 2000,around 20% of registered deaths of HIV patients in France had occurred among good immunovirological responders.

CONCLUSION

To further reduce mortality among such efficiently treated patients, attention must be focused on treatable conditions such as hepatitis C, dyslipidemia and on the prevention of malignancies such as lung cancer and cervical or ano-rectal carcinoma.

Changes in the Pattern of Respiratory Diseases Necessitating Hospitalization of HIV-infectedPatients Since the Advent of Highly Active Antiretroviral Therapy

The incidence rates of opportunistic diseases, hospital admission and death have fallen markedly since the advent of highly active antiretroviral therapy (HAART). We examined the impact of HAART on the pattern of HIV-related respiratory diseases necessitating hospitalization. We retrospectively compared the numbers and etiologies of respiratory diseases diagnosed in HIV-infected patients hospitalized in the chest department of a Paris university hospital during the three years preceding widespread prescription of HAART in France (era 1, starting in July 1993) and the first three years of widespread HAART prescription (era 2, starting in July 1996). Respectively, 207 and 119 HIV-infected patients were admitted for respiratory disease in era 1 and era 2. Only 31.1% of patients admitted during era 2 were receiving HAART. Pulmonary opportunistic infections other than Pneumocystis carinii pneumonia (PCP) (p = 0.0008) and exacerbations of chronic bronchial disease due to gram-negative bacilli (p = 0.04) virtually disappeared in era 2. In contrast, PCP, bacterial pneumonia, tuberculosis, pulmonary Kaposi's sarcoma and pulmonary non-Hodgkin lymphoma showed only a twofold decrease in era 2, while lung cancer was more frequent (p = 0.004). The frequency of severe respiratory diseases necessitating hospitalization of HIV-infected patients has fallen since the advent of HAART, and their etiologic distribution has changed.

Nevirapine and efavirenz elicit different changes in lipid profiles in antiretroviral-therapy-naive patients infected with HIV-1

BACKGROUND

Patients infected with HIV-1 initiating antiretroviral therapy (ART) containing a non-nucleoside reverse transcriptase inhibitor (NNRTI) show presumably fewer atherogenic lipid changes than those initiating most ARTs containing a protease inhibitor. We analysed whether lipid changes differed between the two most commonly used NNRTIs, nevirapine (NVP) and efavirenz (EFV).

METHODS AND FINDINGS

Prospective analysis of lipids and lipoproteins was performed in patients enrolled in the NVP and EFV treatment groups of the 2NN study who remained on allocated treatment during 48 wk of follow-up. Patients were allocated to NVP (n = 417), or EFV (n = 289) in combination with stavudine and lamivudine. The primary endpoint was percentage change over 48 wk in high-density lipoprotein cholesterol (HDL-c), total cholesterol (TC), TC:HDL-c ratio, non-HDL-c, low-density lipoprotein cholesterol, and triglycerides. The increase of HDL-c was significantly larger for patients receiving NVP (42.5%) than for patients receiving EFV (33.7%; p = 0.036), while the increase in TC was lower (26.9% and 31.1%, respectively; p = 0.073), resulting in a decrease of the TC:HDL-c ratio for patients receiving NVP (-4.1%) and an increase for patients receiving EFV (+5.9%; p < 0.001). The increase of non-HDL-c was smaller for patients receiving NVP (24.7%) than for patients receiving EFV (33.6%; p = 0.007), as were the increases of triglycerides (20.1% and 49.0%, respectively; p < 0.001) and low-density lipoprotein cholesterol (35.0% and 40.0%, respectively; p = 0.378). These differences remained, or even increased, after adjusting for changes in HIV-1 RNA and CD4+ cell levels, indicating an effect of the drugs on lipids over and above that which may be explained by suppression of HIV-1 infection. The increases in HDL-c were of the same order of magnitude as those seen with the use of the investigational HDL-c-increasing drugs.

CONCLUSION

NVP-containing ART shows larger increases in HDL-c and decreases in TC:HDL-c ratio than an EFV-containing regimen. Based on these findings, protease-inhibitor-sparing regimens based on non-nucleoside reverse transcriptase inhibitor, particularly those containing NVP, may be expected to result in a reduced risk of coronary heart disease.

The Problems Faced When Assessing the Prevalence and Incidence of Antiretroviral-Related Toxicities

Although the dramatic effect of highly active antiretroviral therapy (HAART) in reducing morbidity and mortality must not be underestimated, it is also important to consider the incidence and prevalence of HAART-related toxicities. Although several studies have investigated HAART-related toxicities, there has been great variety between them in the reported incidence and prevalence rates of these toxicities. Various factors, including whether the study type was a clinical trial or an observational study, the definition of the toxicity endpoints, the demographic characteristics of the study populations and the effect of calendar year on analyses, may all influence the rates observed. We investigated the possible explanations for the differences in the incidence and prevalence rates of HAART-related toxicities between studies, focussing on metabolic and hepatotoxic disorders.

Hypertension in HIV-1-infected patients and its impact on renal and cardiovascular integrity

BACKGROUND

With increasing life spans of HIV-infected individuals under highly active antiretroviral therapy, long-term consequences of the chronic infection and antiretroviral treatment are becoming more prevalent. Data on prevalence and consequences of hypertension are limited, but recent studies suggest that HIV-infected individuals are at a higher risk of developing hypertension.

METHODS

In this prospective study, HIV-1-infected patients from the Frankfurt AIDS Cohort Study (FACS) were followed for 1 year to determine the frequency of systemic hypertension and to assess the associated clinical and demographic factors.

RESULTS

A total 214 HIV-1-infected patients, predominantly Caucasian males, participated in the study. Prevalence of systemic hypertension was 29%. The groups of hypertensive and normotensive individuals were comparable in terms of ethnic background and duration of infection. As in the general population, hypertensive subjects were older (49.1+/-11.1 vs 39.0+/-8.1 years; P<0.0001) and waist-to-hip ratio was higher than in normotensive individuals (0.99+/-0.07 vs 0.93+/-0.08; P<0.0001). Hypertension was associated with a much higher frequency of persistent proteinuria (41.1% vs 2.8%; P<0.001), coronary heart disease (16.1% vs 1.3%; P<0.0001) and myocardial infarction (8.1% vs 0.7%; P<0.005), whereas most cardiovascular risk factors were similar in both groups.

CONCLUSIONS

Our data do not demonstrate any association between the presence of hypertension and antiretroviral therapy or immune status. However, hypertension seems to have a high impact on the existing risk for premature cardiovascular disease. Furthermore, overt proteinuria is frequent in HIV-1 infection with hypertension and might be due to hypertensive nephrosclerosis as well as yet undefined renal disease in these patients.

Incidence of and risk factors for adverse drug reactions in a prospective cohort of HIV-infected adults initiating protease inhibitor-containing therapy

Risk factors associated with the occurrence of protease inhibitor (PI)-related severe and serious adverse drug reactions (SADRs) were analyzed in a prospective cohort of 1155 patients who initiated PI-containing therapy. During a total follow-up of 2037 patient-years, 169 SADRs were reported, yielding a rate of 8 incidents per 100 patient-years (95% confidence interval [CI], 6.8-8.6). The most frequent SADRs were elevated transaminase levels (in 49 events); renal colic (27); abnormal hematological findings (23); and metabolic (18), neuromuscular (7), pancreatic (6), cutaneous (6), cardiovascular (5), and psychiatric disorders (5). Among baseline characteristics, plasma human immunodeficiency virus RNA levels of >or=5 log(10) copies/mL (hazard ratio [HR], 1.5; 95% CI, 1.1-2.2), elevated aspartate aminotransferase levels (HR, 1.1 for each 20 IU of elevation; 95% CI, 1.1-1.2), creatinine clearance levels of <70 mL/min (HR, 2.1; 95% CI, 1.2-3.7), test results positive for hepatitis C virus antibodies or hepatitis B surface antigenemia (HR, 2.6; 95% CI, 1.8-3.7), and receipt of indinavir (HR, 1.7; 95% CI, 1.2-2.4) were independently predictive of a SADR. SADRs were frequent in the first 4 months after initiation of highly active antiretroviral therapy but continued to occur after that time period.

Incidence of non-AIDS-defining cancers before and during the highly active antiretroviral therapy era in a cohort of human immunodeficiency virus-infected patients

PURPOSE

To determine incidence of non-AIDS-defining cancers (NADC) in HIV-infected patients before (P1) and during (P2) the use of highly active antiretroviral therapy (HAART) relative to that observed in the French general population (FGP) of the same age and sex.

PATIENTS AND METHODS

Sex- and age-adjusted NADC standardized incidence ratios (SIR), with FGP as reference, were estimated in 1992 to 1995 (P1) and in 1996 to 1999 (P2) in a French Hospital Database on HIV prospective hospital cohort study.

RESULTS

NADCs were diagnosed in 260 patients during P1 and 391 patients during P2 among the 77,025 patients included in the database between January 1, 1992, and December 31, 1999. Estimated incidence of all cancers was higher in HIV-infected men than in FGP during both periods (P1 SIR = 2.36 and P2 SIR = 1.91). No excess of cancers was observed among HIV-infected women in either period. Incidence of all cancers did not change from P1 to P2 in either sex (SIR = 0.96 for men and 1.00 for women). In contrast, incidence of Hodgkin's disease (HD) was higher than in FGP in both sexes and both periods and increased in P2 as compared with P1; incidence of lung cancer was higher in both sexes during P2.

CONCLUSION

Relative to FGP, the overall incidence of NADCs was increased in HIV-infected men but not in women and did not differ between P1 and P2. Only HD was much more common in HIV infection, and the potential role of HAART on HD cannot be excluded.