Dyslipidemia and fasting glucose impairment among HIV patients three years after the first antiretroviral regimen in a Brazilian AIDS outpatient clinic

Prevalence and characteristics of metabolic syndrome and its components among adults living with and without HIV in Nigeria: a single-center study

BACKGROUND

Persons living with HIV (PLHIV) now live longer due to effective combination antiretroviral therapy. However, emerging evidence indicates that they may be at increased risk for some cardiometabolic disorders. We compared the prevalence of metabolic syndrome (MetS) and its component disorders between persons living with and without HIV in Nigeria.

METHODS

This was a cross-sectional analysis of baseline data from a prospective cohort study of non-communicable diseases among PLHIV along with age- and sex-matched persons without HIV (PWoH) at the University of Abuja Teaching Hospital Nigeria. We collected sociodemographic and clinical data, including anthropometric measures and results of relevant laboratory tests. MetS was defined using a modification of the third report of the National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III) criteria.

RESULTS

Of the 440 PLHIV and 232 PWoH, women constituted 50.5% and 51.3% respectively. The median age of the PLHIV was 45 years while that of the PWoH was 40 years. The prevalence of MetS was 30.7% (95% CI: 26.4%, 35.2%) and 22.8% (95% CI: 17.6%, 28.8%) among the PLHIV and PWoH respectively (P = 0.026). Independent associations were found for older age (P < 0.001), female sex (P < 0.001), family history of diabetes (P < 0.001), family history of hypertension (P = 0.013) and alcohol use (P = 0.015). The prevalence of component disorders for PLHIV versus PWoH were as follows: high blood pressure (22.3% vs 20.3%), prediabetes (33.8% vs 21.1%), diabetes (20.5% vs 8.2%), high triglycerides (24.5% vs 17.2%), low HDL-Cholesterol (51.1% vs 41.4%), and abdominal obesity (38.4% vs 37.1%). Adjusting for age and sex, prediabetes, diabetes, and low HDL-Cholesterol were significantly associated with HIV status. Duration on antiretroviral therapy, protease inhibitor-based regimen, CD4 count, and viral load were associated with some of the disorders mostly in unadjusted analyses.

CONCLUSION

We found a high burden of MetS and its component disorders, with significantly higher prevalence of dysglycemia and dyslipidemia among PLHIV as compared to PWoH. Integration of strategies for the prevention and management of MetS disorders is needed in HIV treatment settings.

Contributory role of ART in the development of non-AIDS comorbidities in asymptomatic PLWHA

BACKGROUND

Despite the many benefits that follow antiretroviral therapy (ART) initiation, its chronic use contributes to the early aging of people living with HIV/AIDS (PLWHA). The aim of this cross-sectional study was to trace the prevalence of and investigate possible renal, bone and metabolic changes, as well as cardiovascular risk in 94 asymptomatic PLWHA, relating them to the duration of ART use.

METHODS

Four groups were evaluated according to ART use: G1 (n = 21), ART-naïve individuals; G2 (n = 17), <2 years; G3 (n = 40), 2-10 years; and G4 (n = 16) on ART for more than 10 years.

RESULTS

Our results showed a high prevalence of dyslipidemic individuals (64%), especially in those under ART. Lower creatine phosphokinase levels were observed in G1 as compared to the others (p < 0.05). Regarding the Framingham score, 12.1% of PLWHA showed moderate and high risk, and the highest proportion (38.5%) occurred in G4 (p = 0.003). A decrease in glomerular filtration rates occurred in 20% of patients, which was also more significant in G3 and G4 (p = 0.007). High prevalences of osteopenia and osteoporosis (53.2%) were found, especially in G1 and G4; however, G1 showed the lowest means for alkaline phosphatases (AP, p = 0.04 and BAP, p = 0.005) and osteocalcin (p = 0.005), in addition to higher vitamin-D concentrations (p = 0.04).

CONCLUSIONS

Our study showed the possible contributory role of ART in these changes, which leads us to reflect on the need for specific conducts and patient care, pointing out the importance of individualized care in an attempt to increase life expectancy.

Incidence of cardiometabolic diseases in a Lesotho HIV cohort: Evidence for policy decision-making

Background

Antiretroviral treatment (ART) has been associated with the development of certain cardiometabolic diseases (CMDs). The burden of CMDs amongst ART-experienced patients in sub-Saharan Africa was unknown.

Objective

We quantified the burden of CMDs and identified the associated risk factors in a large treatment cohort on ART at a high-volume facility in Lesotho.

Methods

In this retrospective cohort study, we extracted data from the daily dispensing electronic system and routine clinical records of 785 adults on ART between 2011 and 2015 in Maseru, Lesotho. CMD was defined as a diagnosis of hypertension, diabetes mellitus or dyslipidaemia (singly or collectively). Descriptive statistics were used to describe the disease burden; Kaplan–Meier curves and cause-specific Cox proportional hazards models were fitted to examine the impact of the ART regimen and identify the risk factors associated with the occurrence of CMD.

Results

Of the 785 participants, 473 (60%) were women. The median age of the group was 42 years, interquartile range (IQR), 36–51 years. The overall incidence of CMD was 5.6 (95% confidence interval [CI] = 4.4–7.1) per 100 person-months of follow-up. The median time to onset of CMD was 16.6 months (IQR = 7.4–23.4). ART was not associated with the occurrence of CMD (cause-specific hazard ratio [CHR] = 1.55; 95% CI = 0.14–16.85; P = 0.72). Higher body mass index (BMI) was associated with the occurrence of diabetes mellitus (CHR = 1.19; 95% CI = 1.14–1.38; P = 0.026).

Conclusion

The incidence of CMD in this relatively young patient population is low yet noteworthy. We recommend that patients living with HIV and AIDS should be routinely screened for CMD. Higher BMI is generally associated with the occurrence of CMD.

Brazilian Protocol for Sexually Transmitted Infections, 2020: HIV infection in adolescents and adults

HIV infection is presented in the chapters of the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020. Health professionals and managers must learn the signs and symptoms of HIV infection and know how to diagnose it to provide appropriate treatment and reduce complications. HIV infection has become a chronic disease. Its treatment includes addressing common comorbidities such as arterial hypertension, diabetes, and dyslipidemia, in addition to cardiac risk assessment, cancer prevention, and guidance on immunization. Initiation of treatment for HIV patients is recommended regardless of clinical or immunological criteria as adopted by the Ministry of Health since 2013. Lately, it has been simplified with more tolerable first-line medications and fewer drug interactions, making its management easy to implement, including by primary health care.

HIV cases are concentrated in specific population groups, such as sex workers, men who have sex with men, transexuals, people who use alcohol or other drugs, and vulnerable people, such as black, incarcerated, or people living on the streets.

[Brazilian Protocol for Sexually Transmitted Infections 2020: HIV infection in adolescents and adults]

HIV infection is the subject of one of the chapters of the "Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections", published by the Brazilian Ministry of Health in 2020. It is important that health professionals and managers learn the signs and symptoms of HIV infection and know how to diagnose it, in order to provide appropriate treatment and reduce complications. HIV infection has become a chronic disease and its treatment includes addressing common comorbidities in clinical practice such as arterial hypertension, diabetes and dyslipidemia, in addition to cardiac risk assessment, cancer prevention and guidance on immunization. Initiation of treatment for all HIV patients, regardless of clinical or immunological criteria, adopted by the Ministry of Health since 2013, has now been simplified with more tolerable first-line medications and with fewer drug interactions, which makes its management easy to implement, including by Primary Health Care.

Aging with HIV in Latin America and the Caribbean: a Systematic Review

PURPOSE OF REVIEW

With the establishment of antiretroviral treatment (ART) programs in low- and middle-income countries, people with HIV (PWH) in Latin America and the Caribbean (LAC) are living longer, subsequently developing chronic non-communicable diseases (NCDs). Few studies focus on the impact of aging among older LAC PWH. This systematic review aims to fill this information gap and understand the burden of aging with HIV in LAC. We identified peer-reviewed literature published in English, Spanish, or Portuguese from several databases to assess currently available evidence on the burden of aging with HIV in LAC and selected six common NCDs found in older PWH (cardiovascular disease [CVD], bone and musculoskeletal [MSK] disorders, cancer, renal disease, neurocognitive impairment [NCI], and depression).

RECENT FINDINGS

Of the 5942 publications reviewed, only 53 articles were found with populations 40 years and older or age-related findings (27 CVD, 13 NCI or depression, 6 MSK disorders, 4 renal disease, 3 cancer). Most (79%) publications were from Brazil with few longitudinal studies on aging with HIV. Prevalence of illnesses such as CVD, NCI, depression, or osteoporosis varied widely depending on the screening instrument utilized and geographic population surveyed. Age was a significant predictor of comorbidity in nearly all studies. Our results demonstrate the need for longitudinal studies and validated screening instruments appropriate for use among PWH in LAC. Understanding the mechanisms behind aging in HIV and the roles of sociocultural factors and genetic diversity specific to LAC is needed to appropriately manage chronic comorbidities as PWH age.

Risk Factors of Leishmania Infection among HIV-Infected Patients in Trang Province, Southern Thailand: A Study on Three Prevalent Species

There are two main species of Leishmania reported in Thailand, that is, Leishmania siamensis and Leishmania martiniquensis. Moreover, leishmaniasis cases caused by Leishmania donovani complex were also reported. There is still a lack of information concerning risk factors of Leishmania infection in Thailand. This study aimed to identify the risk factors of Leishmania infection caused by these three species among HIV-infected patients. A cross-sectional study was conducted in HIV clinic at Trang Hospital, Thailand. Nested PCR and sequencing were performed to detect Leishmania DNA in blood and saliva samples and identify Leishmania species. A standardized questionnaire was used to interview individuals. A total of 526 patients were recruited in this study. Sixty-three (12.0%) were positive for L. siamensis, 24 (4.6%) were positive for L. martiniquensis, and 23 (4.4%) were positive for L. donovani complex. Risk factors of L. siamensis infection included using intravenous drug (adjusted odds ratio [AOR] 2.01, 95% CI: 1.01-4.02). Risk factors of L. martiniquensis infection included female gender (AOR 4.23, 95% CI: 1.52-11.75), using recreational drug (AOR 3.43, 95% CI: 1.00-11.74), and having comorbidities (AOR 4.94, 95% CI: 2.00-12.21). Risk factors of L. donovani complex infection included having opportunistic infection (AOR 4.22, 95% CI: 1.00-17.79), CD4 count 200-500 cells/mm³ (AOR 3.64, 95% CI: 1.14-6.86), and not using insect repellent (AOR 3.04, 95% CI: 1.08-8.58). This study identified the risk factors of Leishmania infection caused by three Leishmania species in Thailand. The data could be useful for disease prevention and control. Further studies on trends of Leishmania infection and preventive measures are recommended.

Incidence and Risk Factors for Prediabetes and Diabetes Mellitus Among HIV-infected Adults on Antiretroviral Therapy: A Systematic Review and Meta-analysis

OBJECTIVE

To summarize evidence on the rates and drivers of progression from normoglycemia to prediabetes and/or diabetes mellitus (hereafter "diabetes") in antiretroviral treatment (ART)-exposed HIV-infected people.

METHODS

We searched EMBASE, PubMed, Web of Science, and Global Index Medicus to identify articles published from 1 January 2000 to 30 April 2017. A random-effects model produced a summary estimate of the incidence across studies and heterogeneity was assessed using Cochrane's Q statistic.

RESULTS

We included 44 studies, whose methodologic quality was high with only 10 (30%) medium-quality studies and none of low quality. There was substantial heterogeneity between studies in estimates of the incidence of diabetes and prediabetes. The pooled incidence rate of overt diabetes and prediabetes were 13.7 per 1,000 person-years of follow-up (95% CI = 13, 20; I = 98.1%) among 396,496 person-years and 125 per 1,000 person-years (95% CI = 0, 123; I = 99.4) among 1,532 person-years, respectively. The major risk factors for diabetes and prediabetes were aging, family history of diabetes, Black or Hispanic origin, overweight/obesity, central obesity, lipodystrophy/lipoatrophy, dyslipidemia, metabolic syndrome, increased baseline fasting glycemia, and certain ART regimens.

CONCLUSIONS

These data highlight the important and fast-increasing burden of diabetes and prediabetes among the ART-exposed HIV-infected population. More research is needed to better capture the interplay between prediabetes/diabetes and ART in HIV-infected patients, considering the increasing number of ART-exposed patients subsequent to the World Health Organization's recommendation of initiating ART at HIV infection diagnosis regardless of CD4 count and age.

Relationship between combination antiretroviral therapy regimens and diabetes mellitus-related comorbidities among HIV patients in Gaborone Botswana

BACKGROUND

Combination antiretroviral therapy (cARTs) regiments are known to prolong the recipients' life even though they are risk factors for diabetes mellitus-related comorbidities (DRCs). We sought to: (i) examine cART relationship with DRCs among patients attending HIV clinics in Gaborone, Botswana (which cART regimens are associated with shorter/longer time to the event), (ii) characterize patients' underlying biomedical and demographic risk factors of DRC and identify the most important, (iii) investigate survival of patients on different cART regimens in the presence of these risk factors.

METHODS

Data from two major HIV clinics in Botswana were reviewed. Relationships between different cART regimens and DRCs were investigated among 531 recipients. Recipients' DRC risk factors were identified. Cox regression model was run. Unadjusted and adjusted hazard ratios were computed, and hazard and survival functions for different cART regimens were plotted.

RESULTS

Major findings were: patients on second- and third-line cART were less likely to develop DRCs earlier than those on first-line cART. Patients with CD4 count ≤ 200 cells/mm3 at cART initiation were more likely to develop DRCs earlier than those who had CD4 count > 200 cells/mm3. Overweight patients at cART initiation had a higher risk of developing DRCs earlier than those who had normal body mass index. Males had a lower risk of developing DRCs earlier than females.

CONCLUSION

The risk of new onset of DRC among cART recipients is a function of the type of cART regimen, duration of exposure and patients' underlying biomedical and demographic DRC risk factors. The study has provided a survival model highlighting DRCs' significant prognostic factors to guide clinical care, policy and management of recipients of cARTs. Further studies in the same direction will likely improve the survival to the development of DRC of every cART recipient in this community.

Metabolic syndrome and cardiovascular disease risk assessment among human immunodeficiency virus-infected individuals on antiretroviral therapy

Background:

The association of cardiovascular risk with first-line antiretroviral therapy (ART) in Indians has been a matter of concern with the background of a high risk in South Asians.

Aims:

This study aimed to compare metabolic syndrome and its components, dyslipidemia, insulin resistance, and cardiovascular risk among patients on first-line ART (Group 1) with age-matched, ART-naïve human immunodeficiency virus (HIV)-infected patients (Group 2) and normal controls (Group 3).

Methods:

Patients attending a tertiary care center in Mysore were enrolled in the study after obtaining informed consent and controls were chosen from relatives of patients.

Results:

The total number of patients enrolled in the study was 217 (males 111; females 106), and the mean age of these patients was 34.1 ± 7.4 years. The number of patients in Group 1 (HIV+, ART experienced) was 76; in Group 2 (HIV+, ART naïve) was 71, and in Group 3 (HIV−) was 70. There was no statistically significant difference in the prevalence of metabolic syndrome between the three groups. On comparing the components of metabolic syndrome, serum triglycerides (mg/dl) were significantly higher in the ART group (Group 1: 149.5 [interquartile range (IQR): 84–187], Group 2: 108 [IQR: 74–152], and Group 3: 141.5 [IQR: 89–192]; P = 0.014) and serum high-density lipoprotein cholesterol was higher in HIV-uninfected individuals (Group 1: 37.5 ± 11.83, Group 2: 31.5 ± 12.23, and Group 3: 40.1 ± 12.09; P = 0.0002). There was no association between metabolic syndrome, duration of HIV, and type of first-line ART. Total and low-density lipoprotein (LDL) cholesterol were significantly higher in the ART group. Homeostatic model assessment and Framingham scores did not reveal any significant difference across the three groups.

Conclusion:

HIV-infected individuals on ART had higher levels of triglycerides, LDL, and total cholesterol, but no increased cardiovascular risk compared to other groups.

Comparison of the ACC/AHA and Framingham algorithms to assess cardiovascular risk in HIV-infected patients

The aim of this study was to compare the predictions of Framingham cardiovascular (CV) risk score (FRS) and the American College of Cardiology/American Heart Association (ACC/AHA) risk score in an HIV outpatient clinic in the city of Vitoria, Espirito Santo, Brazil. In a cross-sectional study 341 HIV infected patients over 40 years old consecutively recruited were interviewed. Cohen's kappa coefficient was used to assess agreement between the two algorithms. 61.3% were stratified as low risk by Framingham score, compared with 54% by ACC/AHA score (Spearman correlation 0.845; p < 0.000). Only 26.1% were classified as cardiovascular high risk by Framingham compared to 46% by ACC/AHA score (Kappa = 0.745; p < 0.039). Only one out of eight patients had cardiovascular high risk by Framingham at the time of a myocardial infarction event registered up to five years before the study period. Both cardiovascular risk scores but especially Framingham underestimated high-risk patients in this HIV-infected population.

High incidence of hypertriglyceridemia in a Brazilian cohort of people living with HIV/AIDS undergoing antiretroviral treatment in Belo Horizonte, 2001-2010

INTRODUCTION:

Hypertriglyceridemia incidence should be estimated in HIV-infected patients after antiretroviral therapy (ART) initiation.

METHODS:

We retrospectively analyzed clinical data of HIV-infected adults at 3 public referral centers. Cumulative and person-time incidences were estimated for patients without hypertriglyceridemia. Survival time and hazard ratio (HR) were estimated by Kaplan-Meier analysis and Cox proportional regression, respectively.

RESULTS:

Cumulative and person-time incidences were 40.4% and 1.4 cases/100 person-months, respectively. The median period for hypertriglyceridemia occurrence was 47 months. Men and patients with switched ART regimens had increased hypertriglyceridemia risk (HR=3.05 and 3.34, respectively).

CONCLUSIONS:

Hypertriglyceridemia incidence is high in HIV-infected patients undergoing ART.

The Initial Months of Antiretroviral Therapy and Its Influence on AGEs, HMGB1, and sRAGE Levels in Asymptomatic HIV-Infected Individuals

The development of the typical comorbidities of aging which currently affects people living with HIV/AIDS (PLWHA) can be partially ascribed to the persistent immune activation and chronic inflammation characterizing these individuals. The aim of this study was to analyze the effect exerted by combined antiretroviral therapy (cART) administration on plasma levels of HMGB1 (high mobility group box protein-1), AGEs (advanced glycation end products), their soluble receptor sRAGE, cytokines, C-reactive protein (CRP), and some metabolic markers in asymptomatic PLWHA. Analyses were performed longitudinally in 30 PLWHA, before and about 6–12 months after cART initiation. We observed that lower levels of AGEs in post-cART group were accompanied by an increase of CRP and triglyceride levels already in the early months of therapy. Because of the current ever-earlier recommendations to start cART and its prolonged use, these and other markers should be investigated in order to monitor and postpone the appearance of non-AIDS comorbidities in PLWHA.

Inhibition of CYP2B6 by Medicinal Plant Extracts: Implication for Use of Efavirenz and Nevirapine-Based Highly Active Anti-Retroviral Therapy (HAART) in Resource-Limited Settings

Highly active antiretroviral therapy (HAART) has greatly improved health parameters of HIV infected individuals. However, there are several challenges associated with the chronic nature of HAART administration. For populations in health transition, dual use of medicinal plant extracts and conventional medicine poses a significant challenge. There is need to evaluate interactions between commonly used medicinal plant extracts and antiretroviral drugs used against HIV/AIDS. Efavirenz (EFV) and nevirapine (NVP) are the major components of HAART both metabolized by CYP2B6, an enzyme that can potentially be inhibited or induced by compounds found in medicinal plant extracts. The purpose of this study was to evaluate the effects of extracts of selected commonly used medicinal plants on CYP2B6 enzyme activity. Recombinant human CYP2B6 was used to evaluate inhibition, allowing the assessment of herb-drug interactions (HDI) of medicinal plants Hyptis suaveolens, Myrothamnus flabellifolius, Launaea taraxacifolia, Boerhavia diffusa and Newbouldia laevis. The potential of these medicinal extracts to cause HDI was ranked accordingly for reversible inhibition and also classified as potential time-dependent inhibitor (TDI) candidates. The most potent inhibitor for CYP2B6 was Hyptis suaveolens extract (IC₅₀ = 19.09 ± 1.16 µg/mL), followed by Myrothamnus flabellifolius extract (IC₅₀ = 23.66 ± 4.86 µg/mL), Launaea taraxacifolia extract (IC₅₀ = 33.87 ± 1.54 µg/mL), and Boerhavia diffusa extract (IC₅₀ = 34.93 ± 1.06 µg/mL). Newbouldia laevis extract, however, exhibited weak inhibitory effects (IC₅₀ = 100 ± 8.71 µg/mL) on CYP2B6. Launaea taraxacifolia exhibited a TDI (3.17) effect on CYP2B6 and showed a high concentration of known CYP450 inhibitory phenolic compounds, chlorogenic acid and caffeic acid. The implication for these observations is that drugs that are metabolized by CYP2B6 when co-administered with these herbal medicines and when adequate amounts of the extracts reach the liver, there is a high likelihood of standard doses affecting drug plasma concentrations which could lead to toxicity.

Availability of data on adverse reactions to antiretroviral drugs in medical charts according to the Naranjo algorithm: an example of a Brazilian historical cohort

BACKGROUND AND OBJECTIVE

Although not designed for research purposes, medical charts can be a unique source for obtaining information on long-term adverse drug reactions. This study aimed to assess the availability of key information on paper-based patient medical records needed to detect long-term adverse reactions to antiretroviral therapy (ART).

METHODS

This is an ongoing historical cohort study carried out in three public HIV/AIDS referral centers in Belo Horizonte, Brazil. Medical charts of treatment-naïve HIV-infected adult patients initiating ART between 2001 and 2005 were reviewed for a follow-up period of up to 5 years after the first ART prescription. Descriptive analysis was performed by estimating the absolute and relative frequencies of selected variables. The Naranjo algorithm was employed to assess the availability of data on long-term adverse outcomes in medical charts.

RESULTS

A total of 233 medical charts were eligible for study and 26.1% contained at least one long-term adverse reaction, corresponding to 45 cases of dyslipidemia (19.3%), 16 (6.9%) of lipodystrophy and 5 of type 2 diabetes mellitus (2.1%). Temporal relationship and ART switch could be better documented from medical charts. Information on reasons for ART switching and alternative causes for adverse reactions was very lacking.

CONCLUSIONS

Specific tools should be developed and included in medical routines to improve adverse reaction reporting by physicians and other health professionals. This could be implemented simultaneously with the transition from paper to electronic medical charts in Brazil, facilitating the identification of long-term adverse reactions to antiretroviral drugs in epidemiological studies and in clinical practice.

Metabolic syndrome in HIV-infected individuals: underlying mechanisms and epidemiological aspects

The success of highly active antiretroviral therapy (HAART) has determined a dramatic decline in AIDS- and immunodeficiency-related causes of death in the HIV-infected population. As life-expectancy increases, such individuals have become gradually exposed not only to the effects of aging itself, but also to the influence of environmental risk factors, which are known to act in the general population. These features can lead to obesity, diabetes mellitus and ultimately cardiovascular diseases (CVD). Metabolic complications and abnormal fat distribution were frequently observed after a few years of antiretroviral therapy and, as the array of antiretroviral drugs became broader, long term metabolic alterations are becoming far more common worldwide. Nevertheless, the risk of not being on HAART is overwhelmingly greater than the metabolic adverse events in terms of morbidity and mortality events. HIV/HAART-induced metabolic unbalances overlap in some extent the components of Metabolic Syndrome (MetS) and its high rates in the HIV population place infected individuals in an elevated CVD risk category. MetS can explain at least in part the emergence of CVD as the major morbidity and mortality conditions in the HIV population. In this review we convey information on the underlying aspects of MetS during HIV infection, highlighting some physiopathological and epidemiological features of this comorbidity along with the role played by HIV itself and the synergy action of some antiretroviral drugs. Considerations on MetS management in the HIV population are also depicted.