Hyperlipidaemia in patients with HIV-1 infection receiving highly active antiretroviral therapy: epidemiology, pathogenesis, clinical course and management

Comparison of Switching Between Antiretroviral Agents Versus Introducing Lipid-lowering Agents for HAART-induced Dyslipidemia

PURPOSE

Highly active antiretroviral therapy (HAART) has brought a significant reduction in HIV/AIDS-related morbidity and mortality. However, metabolic abnormalities (eg, dyslipidemias) have continued to pose significant challenges, warranting a switch between antiretroviral agents and/or the introduction of a statin. Hence, the purposes of this study was to compare the efficacy of switching between antiretroviral agents versus introducing a statin in the long-term management of HAART-induced dyslipidemia in people living with HIV, and to identify the most potent agent in switching therapies.

METHODS

A comprehensive literature search of PubMed and Medline identified articles published from the years 2000 to 2020 in the English language, resulting in 84 articles, 30 of which were selected based on inclusion and exclusion criteria. Information on primary and secondary outcomes was extracted. Statistical analysis was done on the variables, and the differences between groups were considered significant at P < 0.05.

FINDINGS

Statin use was associated with significant reductions in triglycerides and total cholesterol (TC) at 6 weeks (both, P < 0.01). A switch of antiretroviral agents was associated with gradual reductions in TC and triglycerides for up to 48 weeks (both, P < 0.01). Statin use was associated with a reduced CD4 count at 24 weeks (P < 0.01). A switch of antiretroviral agents was associated with an increased CD4 count at 48 weeks (P < 0.01).

IMPLICATIONS

Statins were as effective as switching antiretroviral therapies in the short-term management of TC and triglycerides in patients with HAART-induced dyslipidemia.

Serum Lipid Profiles, Blood Glucose, and High-Sensitivity C-Reactive Protein Levels Among People Living with HIV Taking Dolutegravir and Ritonavir-Boosted Atazanavir-Based Antiretroviral Therapy at Jimma University Medical Center, Southwest Ethiopia, 2021

Background

Long-term use of antiretroviral therapy, especially dolutegravir and boosted-atazanavir, raises concerns about cardiovascular disease. Thus, this study aimed to assess lipid profiles, blood glucose, and high-sensitivity C-reactive protein levels among people living with HIV on dolutegravir and ritonavir-boosted atazanavir-based therapy.

Methods

An institutional-based comparative cross-sectional study was conducted from November 4, 2021, to January 4, 2022. An equal number of dolutegravir- and ritonavir-boosted atazanavir-treated patients (n = 64 each) was enrolled. A consecutive sampling was used to select participants. The Chi-square, Student's t-test, Mann-Whitney U-test, and logistic regression were used as appropriate statistical tests using SPSS Version 25.0. Statistical significance was set at p < 0.05.

Results

Dyslipidemia was found in 67.2% (43/64) of ritonavir-boosted atazanavir group and 48.4% (31/64) of dolutegravir group. The dolutegravir group had significantly higher mean and median values of high-density lipoprotein and random blood sugar, respectively, as well as lower median triglyceride and high-sensitivity C-reactive protein levels than the ritonavir-boosted atazanavir group. Ritonavir-boosted atazanavir-based regimens (AOR=3.4, 95% CI: 1.5, 8) and age >40 years were predictors of dyslipidemia, while BMI ≥25 kg/m2 (AOR=3.7, 95% CI: 1.3, 10.8) and dolutegravir-based regimens (AOR=4.6, 95% CI: 1.5, 14) were predictors of hyperglycemia. Ritonavir-boosted atazanavir-based regimens (ARR=3, 95% CI: 1.3, 8) and BMI ≥25 kg/m2 (ARR=2.5, 95% CI: 1.1, 6) were associated with increased high-sensitivity C-reactive protein by 1-3 mg/L. The risk of increased high-sensitivity C-reactive protein by >3 mg/L was greater in those patients with a CD4 cell count of <500 cells/mm3 (ARR=5, 95% CI: 1.1, 24).

Conclusion

When compared to ritonavir-boosted atazanavir-based regimens, dolutegravir had favorable lipid profiles and high-sensitivity C-reactive protein but unfavorable blood glucose levels. Therefore, baseline blood glucose, lipid profiles, and high-sensitivity C-reactive protein levels should be routinely measured in patients on these regimens.

Effectors of Hyperlipidemia among HIV/AIDS patients with second-line antiretroviral therapy based on register data

OBJECTIVE

In this study, we aimed to determine the prevalence and effectors of hyperlipidemia among people living with HIV/AIDS (PLWHA) and taking second-line antiretroviral therapy (ART) using registry data in central China.

METHODS

We conducted a cross-sectional study and collected information of PLWHA on second-line ART during 2018 from two medical registries. Hyperlipidemia was defined according to the 2016 Chinese guidelines for the management of dyslipidemia in adults. Univariate and multivariate logistic regression analyses were performed to explore the influencing factors of hyperlipidemia. We calculated odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 2886 PLWHA taking second-line ART were included in this study, and 978 (33.9%) had hyperlipidemia. Female patients, those with hyperglycemia, and patients with CD4+ cell counts >500 cells/μL had a higher prevalence of hyperlipidemia with 37.0%, 49.0%, and 41.3%, respectively. Multivariate analysis showed that CD4+ cell count 350-500 cells/μL (OR=1.72, 95% CI: 1.26-2.38), CD4+ cell count >500 cells/μL (OR=2.49, 95% CI: 1.85-3.38), and FPG >6.2 mmol/L (OR=2.08, 95% CI:1.64-2.65) were risk factors for hyperlipidemia. Male sex (OR=0.72, 95% CI: 0.61-0.85) and Hb <110 g/L (OR=0.59, 95% CI: 0.45-0.76) were protective factors against hyperlipidemia.

CONCLUSIONS

PLWHA on second-line ART had a higher prevalence of hyperlipidemia. Gender, CD4+ cell count, FPG, and hemoglobin were influencing factors of hyperlipidemia.

A Step Closer to the "Fourth 90": A Practical Narrative Review of Diagnosis and Management of Nutritional Issues of People Living with HIV

The quality of life of people living with HIV (PLWH) has remarkably increased thanks to the introduction of combined antiretroviral therapy. Still, PLWH are exposed to an increased risk of cardiovascular diseases, diabetes, chronic kidney disease, and liver disease. Hence, the purpose of this review is to summarize the current knowledge about diagnosis and nutritional management with specific indication of macro and micronutrients intake for the main comorbidities of PLWH. In fact, a prompt diagnosis and management of lifestyle behaviors are fundamental steps to reach the "fourth 90". To achieve an early diagnosis of these comorbidities, clinicians have at their disposal algorithms such as the Framingham Score to assess cardiovascular risk; transient elastography and liver biopsy to detect NAFLD and NASH; and markers such as the oral glucose tolerance test and GFR to identify glucose impairment and renal failure, respectively. Furthermore, maintenance of ideal body weight is the goal for reducing cardiovascular risk and to improve diabetes, steatosis and fibrosis; while Mediterranean and low-carbohydrate diets are the dietetic approaches proposed for cardioprotective effects and for glycemic control, respectively. Conversely, diet management of chronic kidney disease requires different nutritional assessment, especially regarding protein intake, according to disease stage and eventually concomitant diabetes.

Prevalence and correlates of dyslipidemia in HIV positive and negative adults in Western Kenya: A cross-sectional study

ABSTRACT

There is increasing morbidity and mortality from cardiovascular diseases (CVD) in sub-Saharan Africa (SSA). Dyslipidemia is a well-known CVD risk factor which has been associated with human immunodeficiency virus (HIV) infection and its treatment in high-income countries. Studies in SSA that have examined the relationship between HIV and dyslipidemia have reported mixed results. In this study, we sought to determine the prevalence of dyslipidemia in HIV positive and negative adults (>=30 years old) and evaluate for association in Western Kenya with a higher prevalence expected among HIV positive individuals.HIV positive adults receiving antiretroviral therapy (ART) and HIV negative individuals seeking HIV testing and counseling services were recruited into a cross-sectional study. Demographic and behavioral data and fasting blood samples were collected. Dyslipidemia was defined according to the National Cholesterol Education Program Adult Treatment Panel III. Associations between baseline demographic and clinical variables and dyslipidemia were analyzed using logistic regression.A total of 598 participants, 300 HIV positive and 298 HIV negative adults were enrolled. Dyslipidemia data was available for 564 (94%) participants. In total, 267 (47%) had dyslipidemia. This was not significantly different between HIV positive and HIV negative individuals (46% vs 49%, P = .4). In a multivariate analysis including both HIV positive and negative individuals, adults 50 to 59 years of age had a 2-fold increased risk of dyslipidemia (Odds ratio [OR] 2.1, 95% confidence interval (1.2-3.5) when compared to 30 to 39-years-old participants. Abdominal obesity (OR 2.5), being overweight (OR 1.9), and low fruit and vegetable intake (OR 2.2) were significantly associated with dyslipidemia. Among HIV positive participants, time since HIV diagnosis, ART duration, use of (PI) protease inhibitor-based ART, viral load suppression, current cluster of differentiation (CD4) count and nadir CD4 did not have significant associations with dyslipidemia.The prevalence of dyslipidemia is high in Western Kenya, with nearly half of all participants with lipid abnormalities. Dyslipidemia was not significantly associated with HIV status, or with HIV-specific factors. Older age, being overweight, abdominal obesity, and low fruit and vegetable intake were associated with dyslipidemia and may be targets for public health interventions to lower the prevalence of dyslipidemia and CVD risk in sub-Saharan Africa.

Raman-based metabonomics unravels metabolic changes related to a first-line tenofovir-based treatment in a small cohort of South African HIV-infected patients

In addition to immunological disorders, human immunodeficiency virus (HIV) also causes metabolic abnormalities. Though successful in viral suppression and immune restoration, continued use of antiretroviral therapy (ART) has also been linked to the development of several metabolic ailments. Currently, the only clinical markers used to manage and monitor the development of HIV-induced metabolic disorders, disease progression as well as observing individual's response to antiviral treatment are CD4 count, viral loads and several other single variable colometric assays. Despite the common use of these clinical markers, these markers remain unreliable and limited in the ability to monitor the development of metabolic disorders as well as monitor treatment response. Given these limitations, it is imperative to discover and develop reliable biological markers for overall HIV disease management. Here, Raman spectroscopy was used to profile metabolic changes in the plasma of 22 HIV⁺ receiving a first-line tenofovir-based combination antiretroviral therapy compared to their 8 HIV⁺ ART^- and 10 HIV^- counterparts. Multivariate statistical analysis was performed in order to classify the samples into their respective groups and to identify significantly altered metabolites between the control and experimental groups. Orthogonal Projections to Latent Structures Discriminant Analysis (OPLS-DA) discriminant analysis identified significant differences (p < 0.05) in 9 different metabolites. Alterations were identified in spectral regions associated with glucose (1124 cm^-1), lipids/phospholipids (1116 cm^-1, 1098 cm^-1, 1077 cm^-1), proteins (1120 cm^-1), nucleic acids (1081 cm^-1) and phenylalanine (1103 cm^-1). Pathway analysis also revealed 3 significantly altered pathways. This study presented the reproducible nature of Raman spectroscopy in distinguishing between HIV-infected (treated and untreated) and uninfected blood plasma and allowed for the detection and identification of treatment induced metabolite changes. The results obtained in the study may, therefore, give insights into understanding the metabolic effect of HIV therapy.

Dyslipidemia in HIV-Infected Children and Adolescents on Antiretroviral Therapy Receiving Care at Kilimanjaro Christian Medical Centre in Tanzania: A Cross-Sectional Study

Background:

Worldwide prevalence of dyslipidemia in HIV-infected children on antiretroviral medications (ARVs) is rising due to extensive use of treatment during their entire lives. Dyslipidemia is the potential side effect of ARVs, especially in individuals taking protease inhibitors. The objective of this study was to determine the prevalence of dyslipidemia in HIV-infected children on ARVs receiving care at Kilimanjaro Christian Medical Centre (KCMC) in Tanzania.

Methods:

This was a cross-sectional hospital-based study conducted from September 2015 to May 2016 at KCMC. HIV-infected children and adolescents less than 17 years on ARVs for more than 6 months were enrolled. Blood samples were taken to determine levels of triglycerides (TGs), total cholesterol, lipoproteins (including low-density lipoprotein (LDL) and high-density lipoprotein (HDL)), CD4+ T cells, and viral load (VL). Anthropometric measurements were used to assess nutritional status. SPSS 20.0 was used for analysis. Logistic regression estimated odds ratio (OR) and 95% confidence interval (CI), and P value <.05 was considered significant. Written consent was obtained from parents/guardians on behalf of their children and assent for older children.

Results:

A total of 260 participants were included in the study; the median age at HIV diagnosis was 3 (interquartile range (IQR) = 1-6) years. The overall prevalence of dyslipidemia was 46.5% with hypercholesterolemia (⩾200 mg/dl) of 11.2%, HDL (<35 mg/dl) of 22.7%, LDL (⩾130 mg/dl) of 7.7%, and hyperglyceridemia (TG ⩾150 mg/dl) of 12.3%. Children aged between 6 and 12 years at HIV diagnosis had 2.7 times higher odds of developing dyslipidemia compared with younger age at diagnosis (OR = 2.7; 95% CI = 1.1-6.6). Patients with advanced (OR = 6.4; 95% CI = 1.5-27.1) or severe (OR = 9.8; 95% CI = 1.2-76.5) HIV-associated immunodeficiency at diagnosis had higher odds of developing dyslipidemia. Protease inhibitor use was associated with higher odds of developing dyslipidemia (OR = 3.1; 95% CI = 1.4-7.1).

Conclusion:

Late diagnosis of HIV at 6 years of age or more, advanced, or severe immunosuppression, and the use of protease inhibitors were independent predictors of dyslipidemia in children on ARVs after 6 months of treatment, and with low HDL levels observed most commonly. Monitoring lipid profiles in children, especially those on protease inhibitors and with advanced/severe immunosuppression at diagnosis, may help in preventing future complications.

HIV-related cardiovascular diseases: the search for a unifying hypothesis

Although the extensive rollout of antiretroviral (ARV) therapy resulted in a longer life expectancy for people living with human immunodeficiency virus (PLHIV), such individuals display a relatively increased occurrence of cardiovascular diseases (CVD). This health challenge stimulated significant research interests in the field, leading to an improved understanding of both lifestyle-related risk factors and the underlying mechanisms of CVD onset in PLHIV. However, despite such progress, the precise role of various risk factors and mechanisms underlying the development of HIV-mediated CVD still remains relatively poorly understood. Therefore, we review CVD onset in PLHIV and focus on 1) the spectrum of cardiovascular complications that typically manifest in such persons and 2) underlying mechanisms that are implicated in this process. Here, the contributions of such factors and modulators and underlying mechanisms are considered in a holistic and integrative manner to generate a unifying hypothesis that includes identification of the core pathways mediating CVD onset. The review focuses on the sub-Saharan African context, as there are relatively high numbers of PLHIV residing within this region, indicating that the greater CVD risk will increasingly threaten the well-being and health of its citizens. It is our opinion that such an approach helps point the way for future research efforts to improve treatment strategies and/or lifestyle-related modifications for PLHIV.

Cardiovascular Complications of HIV in Endemic Countries

Effective combination antiretroviral therapy (ART) has enabled human immunodeficiency virus (HIV) infection to evolve from a generally fatal condition to a manageable chronic disease. This transition began two decades ago in high-income countries and has more recently begun in lower income, HIV endemic countries (HIV-ECs). With this transition, there has been a concurrent shift in clinical and public health burden from AIDS-related complications and opportunistic infections to those associated with well-controlled HIV disease, including cardiovascular disease (CVD). In the current treatment era, traditional CVD risk factors and HIV-related factors both contribute to an elevated risk of myocardial infarction, stroke, heart failure, and arrhythmias. In HIV-ECs, the high prevalence of persons living with HIV and growing prevalence of CVD risk factors will contribute to a growing epidemic of HIV-associated CVD. In this review, we discuss the epidemiology and pathophysiology of cardiovascular complications of HIV and the resultant implications for public health efforts in HIV-ECs.

Cardiovascular disease in patients with HIV

With the progressive increase in life expectancy of HIV-positive patient, thanks to "highly active antiretroviral therapy" (HAART), new comorbidities, and especially cardiovascular diseases (CVDs) are emerging as an important concern. An increased risk of coronary artery disease, often in a younger age, has been observed in this population. The underlying pathophysiology is complex and partially still unclear, with the interaction of viral infection-and systemic inflammation-antiretroviral therapy and traditional risk factors. After an accurate risk stratification, primary prevention should balance the optimal HAART to suppress the virus-avoiding side-effects-the intervention on life-style and the treatment of traditional risk factors (hypertension, dyslipidemia, and diabetes). Also the management after a cardiovascular event is challenging: revascularization strategies-both percutaneous and surgical-are valuable options, keeping in mind the higher rates of recurrent events, and caution is essential to avoid drug-drug interactions. Large evidence-based data on HIV-infected patients are still lacking, and recommendations often follow those of general population. Therefore we performed a comprehensive evaluation of the literature to analyze the current knowledge on CVD's prevalence, prevention and treatment in HIV-infected patients.

HIV Infection and Primary Prevention of Cardiovascular Disease: Lights and Shadows in the HAART Era

With the progressive increase in life-expectancy of human immunodeficiency virus (HIV)-positive patients in the "highly active antiretroviral therapy" (HAART) era, co-morbidities, particularly cardiovascular (CV) diseases (CVD) are emerging as an important concern. The pathophysiology of CVD in this population is complex, due to the interaction of classical CV risk factors, viral infection and the effects of antiretroviral therapy (ARV). The role of ARV drugs in HIV is double edged. While these drugs reduce systemic inflammation, an important factor in CV development, they may at the same time be proatherogenic by inducing dyslipidemia, body fat redistribution and insulin resistance. In these patients primary prevention is challenging, considering the lower median age at which acute coronary syndromes occur. Furthermore prevention is still limited by the lack of robust evidence-based, HIV-specific recommendations. Therefore we performed a comprehensive evaluation of the literature to analyze current knowledge on CVD prevalence in HIV-infected patients, traditional and HIV-specific risk factors and risk stratification, and to summarize the recommendations for primary prevention of CVD in this HIV population.

Endocrine abnormalities in HIV-infected women are associated with peak viral load - the Children and Women: AntiRetrovirals and Markers of Aging (CARMA) Cohort

OBJECTIVES

To investigate the prevalence of endocrine disturbances in a group of HIV-positive (HIV+) women and to identify factors affecting presence of these disorders. To examine specifically whether cellular ageing, as measured by leukocyte telomere length (LTL), is correlated with the presence of endocrine disturbance.

DESIGN

A cross-sectional retrospective substudy of an ongoing prospective cohort study.

PATIENTS

Adult HIV+ (≥19 years) women enrolled in the CARMA (Children and Women: AntiRetrovirals and Markers of Aging) cohort study (N = 192). Prevalences of T2DM, glucose intolerance, dyslipidaemia, thyroid disorders, adrenal insufficiency, hypogonadism, primary ovarian insufficiency (POI), demographics, HIV and hepatitis C virus (HCV) infection status, baseline LTL, combined antiRetroviral therapy (cART) and substance exposures were collected. Statistical analysis included univariable followed by multivariable Poisson regression and step-wise reduction to refine the multivariable model.

RESULTS

Prevalence of any endocrine abnormality was 58% (dyslipidaemia 43%, glucose intolerance/T2DM 13%, thyroid disorders 15%). In multivariable analysis, age was associated with number and type (any, glucose, lipid) of abnormality, while increasing body mass index (BMI) was associated with number of diagnoses and with glucose metabolism disorders. Interestingly, peak HIV pVL ≥100 000 copies/ml was associated with any abnormality, total number of disorders and presence of a thyroid disorder, while any disorder, glucose abnormalities and dyslipidaemia were negatively associated with alcohol use. LTL was not associated with number or type of endocrine abnormalities in this study.

CONCLUSION

Further studies examining the relationship between duration and extent of exposure to HIV viraemia in relation to developing abnormal endocrine function are warranted.

High Prevalence of Metabolic Syndrome and Cardiovascular Disease Risk Among People with HIV on Stable ART in Southwestern Uganda

The objectives of this study were to determine the epidemiology and correlates of cardiovascular disease (CVD) risk among Ugandans on first-line antiretroviral therapy (ART). We conducted a cross-sectional study at an HIV clinic in southwestern Uganda. We enrolled adult patients on non-nucleoside-based ART regimens for a minimum of 2 years. We collected anthropometric and clinical measurements, smoking history, and blood for fasting lipid profile and blood sugar (FBS). Outcomes of interest were (1) presence of metabolic syndrome (at least two of the following: FBS >100 mg/dL, blood pressure of ≥130/85 mmHg, triglycerides ≥150 mg/dL, HDL <40 mg/DL, or waist circumference ≥94 cm in males or ≥80 cm in females); and (2) a Framingham score correlating to >5% 10-year CVD risk. Of the 250 participants enrolled, metabolic syndrome was detected in 145/250 (58%) of participants (62% in females and 50% in males). Forty-three participants (17%) had a Framingham risk correlating to a 5% or greater risk for CVD within 10 years (26% in males and 13% in females). In multivariate analyses, being female (AOR 3.13; 95% CI: 1.0-9.70; p = 0.04) and over 40 years of age (AOR 1.78; 95% CI: 1.00-3.17; p = 0.05) was independently associated with having metabolic syndrome. We found no independent risk factors for a Framingham risk score 10-year risk exceeding 5%, or associations between ART regimen and CVD risk profiles. We conclude that metabolic abnormalities are common among patients on first-line ART in rural Uganda, and appear to be more common in women than men.

Is the atherosclerotic process accentuated under conditions of HIV infection, antiretroviral therapy, and protease inhibitor exposure? Meta-analysis of the markers of arterial structure and function

OBJECTIVE

To evaluate the apparent association of human immunodeficiency virus (HIV) infection, antiretroviral therapy (ART), and protease inhibitor (PI) exposure with the functional and structural markers of vasculature.

METHODS

A meta-analysis of the relationship between HIV infection, ART, and PI exposure and the functional and structural markers of vasculature. A systematic literature search was performed electronically using specific eligibility criteria. Weighted mean difference (WMD) and corresponding 95% confidence interval (CI) were calculated and combined appropriately.

RESULTS

Fifty-seven articles were included with nine different outcomes. Compared with HIV-negative patients, HIV-positive patients demonstrated significant elevated intima-media thickness (IMT) (WMD (95% CI) = 0.042 (0.028-0.057)), increased pulse wave velocity (PWV) (0.538 (0.283-0.792)), and reduced flow-mediated vasodilation (FMD) (-2.049 (-2.806 to -1.293)). Elevated IMT was observed in HIV patients receiving ART when compared with those naïve to ART in the 20- to 40-year-old age group (0.078 (0.033-0.123)), the >40-year-old age group (0.038 (0.018-0.057)), and the group comprising >50% males (0.070 (0.041-0.099)). In addition, ART resulted in an increased PWV in HIV patients receiving ART in the group with >50% male proportion (0.628 (0.405-0.851)). HIV patients exposed to PI showed a significant trend toward elevated IMT (0.033 (0.007-0.058)) and increased PWV (0.264 (0.118-0.410)) compared with those without PI exposure.

CONCLUSIONS

The atherosclerotic process was accentuated by elevated IMT, increased PWV, and reduced FMD under condition of HIV infection. Comparison of ART-receiving with ART-naïve patients showed a significant trend toward elevated IMT and increased PWV, especially under treatment with PI-containing drugs.

Lipid profile of HIV-infected patients in relation to antiretroviral therapy: a review

This study reviewed the lipid profile of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients in relation to use of antiretroviral therapy (ART), and its different classes of drugs. A total of 190 articles published in peer-reviewed journals were retrieved from PubMed and LILACS databases; 88 of them met the selection criteria and were included in the review. Patients with HIV/AIDS without ART presented an increase of triglycerides and decreases of total cholesterol, low density lipoprotein (LDL-c), and high density lipoprotein (HDL-c) levels. Distinct ART regimens appear to promote different alterations in lipid metabolism. Protease inhibitors, particularly indinavir and lopinavir, were commonly associated with hypercholesterolemia, high LDL-c, low HDL-c, and hypertriglyceridemia. The protease inhibitor atazanavir is apparently associated with a more advantageous lipid profile. Some nucleoside reverse-transcriptase inhibitors (didanosine, stavudine, and zidovudine) induced lipoatrophy and hypertriglyceridemia, whereas abacavir increased the risk of cardiovascular diseases even in the absence of apparent lipid disorders, and tenofovir resulted in lower levels of cholesterol and triglycerides. Although non-nucleoside reverse-transcriptase inhibitors predisposed to hypertriglyceridemia and hypercholesterolemia, nevirapine was particularly associated with high HDL-c levels, a protective factor against cardiovascular diseases. Therefore, the infection itself, different classes of drugs, and some drugs from the same class of ART appear to exert distinct alterations in lipid metabolism.

Impact of efavirenz on intestinal metabolism and transport: insights from an interaction study with ezetimibe in healthy volunteers

Hypercholesterolemia frequently occurs in patients treated with efavirenz who cannot be treated adequately with statins because of drug interactions. These patients may benefit from cholesterol-lowering therapy with ezetimibe. This study determined the influence of single-dose and multiple-dose efavirenz (400 mg/day for 9 days) on the pharmacokinetics and sterol-lowering of ezetimibe (10 mg) in 12 healthy subjects. In addition, the influence of efavirenz on genome-wide intestinal expression and in vitro function of ABCB1, ABCC2, UGT1A1, and OATP1B1 was studied. Efavirenz (multiple dose) had no influence on the pharmacokinetics and lipid-lowering functions of ezetimibe. Intestinal expression of enzymes and transporters (e.g., ABCB1, ABCC2, and UGT1A1) was not affected by chronic efavirenz. Efavirenz (single dose) slightly increased ezetimibe absorption and markedly decreased exposure to ezetimibe-glucuronide (single dose and multiple dose), which may be explained by inhibition of UGT1A1 and ABCB1 (in vitro data). Ezetimibe had no effect on the disposition of efavirenz. Consequently, ezetimibe may be a safe and efficient therapeutic option in patients with HIV infection.

Effect of specific ART drugs on lipid changes and the need for lipid management in children with HIV

BACKGROUND

We investigated the effects of individual antiretrovirals on lipids in HIV-infected children and the proportion potentially eligible for dietary or pharmacologic intervention.

METHODS

St Mary's and Great Ormond Street Hospital's, London, United Kingdom, patients between 1995 and 2007 were included. Associations between lipids (millimoles per liter) and specific antiretroviral therapy were assessed using mixed-effects models adjusted for confounders. Children eligible for lipid-lowering management were assessed according to American Academy of Pediatric criteria [low-density lipoprotein (LDL) > 190 mg/dL or 4.9 mmol/L for children with no known cardiovascular disease risk factors or LDL > 160 mg/dL or 4.1 mmol/L for children with 2 or more cardiovascular disease risk factors].

RESULTS

Four hundred forty-nine children had median 4.5-year follow-up. On average, antiretroviral therapy-naive children had normal lipids except for low high-density lipoprotein cholesterol (HDL) (median 0.8). All cholesterol subsets were elevated for the 4 drugs assessed. Protease inhibitors had greater rises in total cholesterol with the maximal non-HDL rise for lopinavir/ritonavir at 4+ years of exposure, 0.8 (0.57-1.03). The nonnucleoside reverse transcriptase inhibitors also raised non-HDL, but this was associated with additional clinically significant increases in HDL. Nevirapine raised non-HDL by 0.38 (0.09-0.31) at 2-3 years and HDL by 0.34 (0.28-0.41). Efavirenz raised non-HDL by 0.2 (0.09-0.31) and HDL by 0.12 (0.08-0.17) at 1 year. Ten percent had LDL above the 95th percentile, but only 3 met the 4.9 cutoff for pharmacologic intervention.

CONCLUSIONS

Intervention strategies (dietary and exercise advice, treatment switching, and pharmacotherapy) are required for persistent hyperlipidemia and should be assessed in randomized control trials.

The assessment of metabolic syndrome in UK patients with HIV using two different definitions: CREATE 2 study

OBJECTIVE

To determine the prevalence and clinical associations of the metabolic syndrome (M-IRS) in an HIV cohort.

METHODS AND DESIGN

Data was collected prospectively on demographics, anthropometry, HIV disease, drug regimens and cardiometabolic risk factors using a two-centre cross-sectional cohort study design. M-IRS was diagnosed by National Cholesterol Education Program (NCEP) and International Diabetes Federation (IDF) criteria.

RESULTS

The prevalence of M-IRS in 678 subjects was 14% by NCEP and 10% by IDF. One feature of the M-IRS was present in 68%, while 37% had two or more features. Increased waist circumference was found in 32% by NCEP or by IDF criteria, hypertriglyceridaemia in 32%, reduced HDL-C in 27%, 18% had raised systolic blood pressure and 13% had dysglycaemia. Protease inhibitor (PI) usage was similar in both M-IRS categories (43 vs. 38%; p = 0.38) but increased use of efavirenz was seen in M-IRS (47 vs. 36%; p = 0.07) and nevirapine in the non-M-IRS groups (10 vs. 20%; p = 0.05). Multiple drug therapies were associated with raised triglyceride levels while nevirapine therapy was associated with raised HDL-C and abacavir with dysglycaemia.

CONCLUSIONS

The prevalence of M-IRS in this HIV cohort was similar to the general population and independent of current or previous highly active antiretroviral therapy (HAART) or its duration. Given the relationship between individual drugs and features of M-IRS its significance must be interpreted in the light of probable accrual bias in prescribing. Prospective studies are required to ascertain the cardiometabolic risk factors to include in a prognostically useful HIV disease-specific definition of M-IRS.

Efficacy and safety of atazanavir-ritonavir plus abacavir-lamivudine or tenofovir-emtricitabine in patients with hyperlipidaemia switched from a stable protease inhibitor-based regimen including one thymidine analogue

Randomized, open-label, prospective clinical trial assessing efficacy and safety on hyperlipidemia of a switching from a regimen including one protease inhibitor and one thymidine analogue to atazanavir/ritonavir plus abacavir/lamivudine or tenofovir/emtricitabine. Adult HIV-infected patients on their first antiretroviral therapy (of at least 48-week duration), including one protease inhibitor and zidovudine or stavudine, with stable immunovirologic features, and having diagnosis of persisting hyperlipidemia, were randomized to replace current treatment with atazanavir/ritonavir plus abacavir/lamivudine (arm A) or tenofovir/emtricitabine (arm B), and were followed for 48 weeks. Eighty-nine patients were enrolled: 42 patients were randomized to arm A, and 47 to arm B. At the end of the 48-week follow-up, incidence of virologic failure was comparable in both arms, and associated with a poor drug compliance. Increase in CD4 lymphocyte count was significantly higher in arm A after a 24-week study period (62.5 versus 39.2 x 10(6) cells/L; p < 0.05), while immunologic responses were comparable at the end of 48-week follow-up (91.5 versus 83.6; p > 0.05). A statistically significant reduction (-15.4%) in mean triglyceridaemia versus respective baseline values was reported in both groups (p < 0.05), without statistically significant difference between arm A and B. Similar results were reported for total cholesterol and low-density lipoprotein (LDL) cholesterol levels. Safety and tolerability profiles were comparable in both groups. Switching from a protease inhibitor- and thymidine analogue-based antiretroviral regimen to atazanavir/ritonavir plus abacavir/lamivudine or tenofovir/emtricitabine proved effective in the management of hyperlipidemia, without significant differences in lipid-lowering effect, virologic efficacy, and safety profile between these regimens.

ORIGINAL ARTICLE Posterior Intracorneal Opacities in Patients with HIV Infection

PURPOSE

To describe a keratopathy in patients with the human immunodeficiency virus (HIV) infection.

METHODS

Retrospective review of ophthalmic and medical records, including laboratory evaluations, of seven patients with HIV infection and posterior intracorneal opacities.

RESULTS

Each patient had a bilateral peripheral keratopathy located at the level of the Descemet membrane that was unassociated with intraocular inflammation. All patients were receiving highly active antiretroviral therapy (HAART). All patients had elevations in their CD4+ T-lymphocyte counts due to HAART prior to presenting with the corneal opacities. Five of the seven patients had elevated serum cholesterol, triglycerides, or both. Best-corrected visual acuity was 20/25 or better in six of the seven patients at the time of diagnosis, and vision remained stable through the follow-up period in all patients (median follow-up: 25 months; range: 14-82 months). The corneal opacities remained unchanged in all seven over the follow-up period.

CONCLUSION

These patients have a bilateral keratopathy that appears to be non-progressive and has no effect on visual acuity.

Comparative 1H NMR-based metabonomic analysis of HIV-1 sera

(1)H NMR spectroscopy of sera from HIV-1 infected and uninfected individuals was performed on 300 and 600 MHz instruments. The resultant spectra were automatically data reduced to 90 and 180 integral segments of equal length. Analysis of variance identified significant differences between the sample groups, especially for the samples analyzed on 600 MHz and reduced to fewer segments. Linear discriminant analysis correctly classified 100% of the samples analyzed on the 300 MHz NMR (reduced to 180 segments); an increase in instrument sensitivity resulted in lower percentages of correctly classified samples. Multinomial logistic regression (MLR) resulted in 100% correct classification of all samples from both instruments. Thus (1)H-NMR metabonomics on either instrument distinguishes HIV-positive individuals using or not using anti retroviral therapy, but the sensitivity of the instrument impacts on data reduction. Furthermore, MLR is a novel multivariate statistical technique for improved classification of biological data analyzed in NMR.

A case study and review of pancreatitis in the AIDS population

This case study considers a 55-year-old African American woman with the acquired immunodeficiency syndrome (AIDS) who presented with epigastric abdominal pain for 1 week. She was found to have pancreatitis on computed tomography scanning. Unique to this case are the numerous possible etiologies of her pancreatitis. Thus, this case study systematically reviews the different etiologies of pancreatitis in the AIDS population compared to the general population. Furthermore it discusses the management and treatment of pancreatitis in AIDS.

Fish oil and fenofibrate for the treatment of hypertriglyceridemia in HIV-infected subjects on antiretroviral therapy: results of ACTG A5186

INTRODUCTION

Fish oil has been shown to reduce serum triglyceride (TG) concentrations. In HIV-infected patients on antiretroviral therapy, high TG concentrations likely contribute to increased risk of cardiovascular disease. AIDS Clinical Trials Group A5186 examined the safety and efficacy of fish oil plus fenofibrate in subjects not achieving serum TG levels < or =200 mg/dL with either agent alone.

METHODS

One hundred subjects on highly active antiretroviral therapy with serum TG concentrations > or =400 mg/dL and low-density lipoprotein cholesterol < or =160 mg/dL were randomized to 3 g of fish oil twice daily or 160 mg of fenofibrate daily for 8 weeks. Subjects with a fasting TG level >200 mg/dL at week 8 received a combination of fish oil and fenofibrate in the same doses from week 10 to week 18.

RESULTS

Median baseline TG was 662 mg/dL in the fish oil group and 694 mg/dL in the fenofibrate group (P = not significant). Fish oil reduced TG levels by a median of 283 mg/dL (46%), fenofibrate reduced them by 367 mg/dL (58%), and combination therapy reduced them by 65.5%. Combination therapy achieved TG levels of < or =200 mg/dL in 22.7% subjects. Fish oil had no measurable effect on immunologic parameters or the pharmacokinetics of lopinavir.

CONCLUSIONS

Fish oil was safe when administered alone or combined with fenofibrate and significantly reduced TG levels in HIV-infected subjects with hypertriglyceridemia.

Two immunomodulators, curcumin and sulfasalazine, enhance IDV antiretroviral activity in HIV-1 persistently infected cells

Since the appearance of resistance to antiretroviral treatment is unavoidable, the host cell's transcription factor NF-kappaB is a novel HIV target. The goal of this study was to characterize the effect of two immunomodulators, curcumin (Cur) and sulfasalazine (Sul), with a protease inhibitor, indinavir (IDV), on HIV-1 persistently infected CD4+ T-cells. Viral p24 antigen production, viral infectivity (tested on MAGI cells) and viral relative infectivity (viral infectivity/p24) were analysed. When used alone, both immunomodulators were able to reduce viral infectivity. When in combination, both 10 microM IDV plus 10 microM Cur and 10 microM IDV plus 250 microM Sul showed a significant reduction in viral infectivity and viral relative infectivity when compared to the reduction produced by IDV alone. Thus, the use of immunomodulators with IDV could help to reduce HIV-1 production in persistently infected cells.

Contraception use and pregnancy among 15-24 year old South African women: a nationally representative cross-sectional survey

BACKGROUND

Adolescent reproductive health has not continued to receive the attention it deserves since the start of the HIV epidemic. In South Africa, high numbers of adolescent women report pregnancies that are unwanted and yet few have accessed available termination of pregnancy services. Enabling contraception use is vital for meeting the goals of HIV prevention.

METHODS

A nationally representative survey of South African 15-24 year olds was undertaken. Participants completed a questionnaire on sexual behaviour and provided an oral fluid sample for HIV testing. Analysis of the data was restricted to women (n = 6217), particularly those who reported being sexual active in the last 12 months (n = 3618) and was conducted using svy methods in the program STATA 8.0 to take account of sampling methods. Univariate and multivariate analyses were conducted to explore factors associated with contraceptive use.

RESULTS

Two thirds of all women reported having ever been sexually active and among these 87% were sexually active in the past 12 months. Among women who reported currently being sexually active, 52.2% reported using contraceptives. There was evidence of association between contraceptive use and being employed or a student (vs unemployed); fewer sex partners; type of last sex partner; having talked to last partner about condom use and having ever been pregnant.

CONCLUSION

Specific emphasis must be placed on encouraging young women to use contraceptive methods that offer protection against pregnancy and STIs/HIV. Our consistent finding of a relationship between discussing condom use with partners and condom use indicates the importance of involvement of male partners in women's contraceptive decisions.

Pharmacokinetics and Pharmacodynamics of Combined use of Lopinavir/Ritonavir and Rosuvastatin in HIV-Infected Patients

Background

Lopinavir/ritonavir-containing antiretro-viral therapy can cause hyperlipidaemia. However, most statins are contraindicated due to drug-drug interactions. Rosuvastatin undergoes minimal metabolism by CYP450, so no CYP450-based interaction with lopinavir/ritonavir is expected. This study explored the lipid-lowering effect of rosuvastatin and assessed the effect of lopinavir/ritonavir on the pharmacokinetics of rosuvastatin and vice versa.

Methods

HIV-infected patients on lopinavir/ritonavir (viral load <400 copies/ml) with total cholesterol (TC) >6.2 mmol/l were treated with rosuvastatin for 12 weeks, starting on 10 mg once daily. If fasting target values (TC<5.0 mmol/l, high-density lipoprotein-cholesterol >1.0 mmol/l, low-density lipoprotein-cholesterol [LDL-c] <2.6 mmol/l and triglycerides <2.0 mmol/l) were not reached, rosuvastatin was escalated to 20 mg or 40 mg at week 4 and 8, respectively. Plasma lopinavir/ritonavir trough levels (Cmin) were determined at week 0, 4, 8 and 12 and rosuvastatin Cmin, at week 4, 8 and 12.

Results

Twenty-two patients completed the study. Mean reductions in TC and LDL-c from baseline to week 4 (on rosuvastatin 10 mg once a day) were 27.6% and 31.8%, respectively. Lopinavir/ritonavir concentrations were not influenced by rosuvastatin ( P=0.44 and 0.26, repeated-measures analysis). Median (interquartile range) rosuvastatin Cmin for 10 mg, 20 mg and 40 mg once daily were 0.97 (0.70–1.5), 2.5 (1.3–3.3) and 5.5 (3.3–8.8) ng/ml, respectively.

Conclusions

Rosuvastatin appeared to be an effective statin in hyperlipidaemic HIV-infected patients. Lopinavir/ritonavir levels were not affected by rosuvastatin, but rosuvastatin levels unexpectedly appeared to be increased 1.6-fold compared with data from healthy volunteers. Until safety and efficacy have been confirmed in larger studies, the combination of rosuvastatin and lopinavir/ritonavir should be used with caution.

The coming problem of HIV-associated Alzheimer's disease

BACKGROUND

Dementia associated with human immunodeficiency virus (HIV) is a subcortical neuropathology that does not resemble Alzheimer's disease. However, several lines of evidence suggest that in the future there may be significant numbers of long-term HIV survivors with true Alzheimer's disease. Age is itself a risk factor Alzheimer's disease, and an aging population and widespread use of highly active antiretroviral therapy (HAART) means more elderly HIV patients. Immune reconstitution inflammatory syndrome, lypodystrophic effects of HAART medications, HIV-induced amyloid deposition and excitotoxic effects of gp120 and TAT protein all could be risk factors for subsequent Alzheimer's disease. Finally, HIV patients will have greater vulnerability to common non-HIV pathogens that may contribute to development of Alzheimer's disease.

PRESENTATION OF THE HYPOTHESIS

It is predicted that in the future there will be seen measurable numbers of long-term HIV survivors on HAART who have Alzheimer's disease, with a cortical deficit profile on neuropsychological tests, pronounced cerebral atrophy seen on brain MRI, and neurofibrillary tangles, senile plaques and neuronal loss in post-mortem brain tissue. VALIDATING THE HYPOTHESIS: The hypothesis could be validated through case reports, longitudinal clinical studies, brain bank programs and animal models.

IMPLICATIONS OF THE HYPOTHESIS

Management of HIV may become more difficult, requiring greater provisions for long-term care of HIV patients with chronic dementia. However, it may be possible to reduce or prevent HIV-associated Alzheimer's disease through early use of cholinesterase inhibitors, glutamate-blocking drugs, insulin sensitizing agents, statins and anti-oxidants.

Reduction in triglyceride level with N-3 polyunsaturated fatty acids in HIV-infected patients taking potent antiretroviral therapy: a randomized prospective study

To assess the evolution of triglyceride (TG) levels in HIV-infected patients receiving stable potent antiretroviral therapy treated with N-3 polyunsaturated fatty acids (PUFAs), a prospective double-blind randomized design for a reliable assessment of TG evolution was performed. One hundred twenty-two patients with TG levels >2 g/L and < or =10 g/L after a 4-week diet (baseline TG: 4.5 +/- 1.9 g/L) were randomized for 8 weeks to N-3 PUFAs (2 capsules containing 1 g of fish oil 3 times daily, n = 60), or placebo (1 g of paraffin oil capsules, n = 62). An 8-week open-label phase of N-3 PUFAs followed. Evaluation criteria were TG percent change at week 8, percentage of responders (normalization or > or =20% TG decrease), and safety issues. Ten patients with baseline TG levels >10 g/L were not randomized and received N-3 PUFAs as open treatment. The difference (PUFA - placebo) in TG percent change at week 8 was -24.6% (range: -40.9% to -8.4%; P = 0.0033), the median was -25.5% in the PUFA group versus 1% in the placebo group, and mean TG levels at week 8 were 3.4 +/- 1.8 g/L and 4.8 +/- 3.1 g/L, respectively. TG levels were normalized in 22.4% (PUFA) versus 6.5% (placebo) of patients (P = 0.013) with a > or =20% reduction in 58.6% (PUFA) versus 33.9% (placebo) of patients (P = 0.007). Under the open-label phase of N-3 PUFAs, the decrease in TG levels was sustained at week 16 for patients in the PUFA group (mean TG: 3.4 +/- 1.7 g/L), whereas a 21.2% decrease in TG levels occurred for patients in the placebo group (mean TG: 3.3 +/- 1.4 g/L). No significant differences were observed between groups in the occurrence of adverse events. The median TG change at week 8 was -43.6% (range: Q1-Q3; 95% CI: -66.5% to -4.6%) for patients with baseline TG levels >10 g/L. The difference in mean total cholesterol between groups (PUFA - placebo) at week 8 was -8.5% (P = 0.0117). This study demonstrated the efficacy of PUFAs to lower elevated TG levels in treated HIV-infected hypertriglyceridemic patients. N-3 PUFAs have a good safety profile.

Randomized open-label trial of two simplified, class-sparing regimens following a first suppressive three or four-drug regimen

OBJECTIVES

Complex antiretroviral regimens can be associated with increased toxicity and poor adherence. Our aim was to compare the efficacy and safety of switching to two simplified, class-sparing antiretroviral regimens.

METHODS

We conducted a randomized, open-label study in 236 patients with virologic suppression who were taking a three- or four-drug protease inhibitor or non-nucleoside reverse transcriptase inhibitor regimen for > or = 18 months. Patients received lopinavir/ritonavir (LPV/r) 533 mg/133 mg twice daily + efavirenz (EFV) 600 mg once daily or EFV + two nucleoside reverse transcriptase inhibitors (NRTI). Primary study endpoint was time to first virologic failure (VF, confirmed HIV-1 RNA > 200 copies/ml) or discontinuation because of study drug-related toxicity.

RESULTS

After 2.1 years of follow up, patients receiving LPV/r + EFV discontinued treatment at a greater rate than patients receiving EFV + NRTI (P < 0.001). Twenty-one patients developed VF (14 receiving LPV/r + EFV and seven receiving EFV + NRTI) and 26 discontinued because of a study drug-related toxicity (20 receiving LPV/r + EFV and six receiving EFV + NRTI). Time to VF or study drug related-toxicity discontinuation was significantly shorter for LPV/r + EFV than EFV + NRTIs (P = 0.0015). A significantly higher risk of drug-related toxicity occurred with LPV/r + EFV, mainly for increased triglycerides (P = 0021). A trend toward a higher VF rate occurred with LPV/r + EFV in an intent-to-treat and as-treated analyses (P = 0.088 and P = 0.063 respectively).

CONCLUSIONS

Switching to EFV + NRTI resulted in better outcomes, fewer drug-related toxicity discontinuations and a trend to fewer virologic failures compared to switching to LPV/r + EFV.

Atherosclerosis and central adiposity in a pediatric patient with AIDS treated with HAART: autopsy findings

Several types of cardiovascular lesions may develop in pediatric human immunodeficiency virus-positive (HIV+)/acquired immunodeficiency syndrome (AIDS) patients, namely myocarditis, dilated cardiomyopathy, pericardial effusion, pericarditis, left ventricle hypertrophy, fibrocalcific arteriopathy, and aneurysms. Additional lesions may be discovered by histological examination. These include fibrocalcific lesions in medium-sized arteries and small vessels, mainly of the heart and brain, and vasculitis. In the large arteries the vasa vasorum may present chronic inflammatory infiltrates or leukocytoclastic vasculitis, resulting in aneurysms. We are reporting the case of a 14-year-old girl with mother-to-infant HIV transmission with a long history of several central nervous system infections and AIDS dementia, who received treatment with the HAART protocol (including a protease inhibitor) for 3 years. A year after beginning this treatment, cholesterol serum levels were 2.8 g/L and 3.8 g/L. Autopsy findings showed gross and microscopic features of adult-type atherosclerosis involving the whole thoracic aorta, its main branches, and the coronary arteries. Remarkably, the abdominal aorta and all its branches were almost completely devoid of these lesions. At the same time, although the body presented extreme cachexia, there were obvious subepericardial, periadrenal, and peripancreatic fat deposits. The referred findings may have resulted from the well-known metabolic-dyslipemic syndrome induced by the HAART therapy and have not been specifically mentioned previously in the literature in the particular setting observed in the case of this patient.

Applying biofluid 1H NMR-based metabonomic techniques to distinguish between HIV-1 positive/AIDS patients on antiretroviral treatment and HIV-1 negative individuals

Metabonomics, the study of metabolites and their role in various physiological states, is a novel methodology arising from the post-genomics era and has extensive biomedical application. This technology has exhibited vast success in the identification and study of human diseases and may find further application in the study of HIV/AIDS. Specifically, the wide range of clinical and metabolic abnormalities associated with the use of antiretroviral (ARV) treatment may be investigated. To this end, this preliminary study evaluated whether metabonomic techniques could distinguish between HIV-1 positive/AIDS patients utilizing antiretroviral therapy and HIV-1 negative individuals. Serum metabolic profiles determined by 1H nuclear magnetic resonance (NMR) spectroscopy combined with pattern recognition analysis of the data showed that this distinction was attainable; suggesting that ARV-associated side-effects could be monitored utilizing NMR metabonomic techniques.

Lipodystrophy: lessons in lipid and energy metabolism

PURPOSE OF REVIEW

Lipodystrophies are rare inherited and acquired disorders characterized by the selective loss of adipose tissue. Despite marked phenotypic and genotypic heterogeneity, most lipodystrophic syndromes predispose to similar metabolic complications seen in patients with obesity, such as insulin resistance, diabetes mellitus, hepatic steatosis and dyslipidemia. The purpose of this review is to highlight the current understanding of the mechanisms underlying dyslipidemia in patients with lipodystrophies.

RECENT FINDINGS

Marked hypertriglyceridemia and reduced levels of high-density lipoprotein cholesterol are commonly seen, and the severity of these metabolic abnormalities seems to be related to the extent of fat loss. The precise mechanisms by which the lack of adipose tissue causes hypertriglyceridemia remain unknown. Anecdotal kinetic studies in hyperglycemic patients with lipodystrophies have revealed accelerated lipolysis and increased free fatty acid turnover, which drives hepatic triglyceride and very low-density lipoprotein synthesis. Other mechanisms may also be involved in causing dyslipidemia and ectopic triglyceride accumulation in the liver and skeletal muscles that remain to be identified.

SUMMARY

Understanding the pathophysiology of dyslipidemia in these rare disorders of lipodystrophies may offer insights into the normal role of adipocytes in maintaining metabolic homeostasis, and its disturbances in common forms of obesity.

Effects of 5 HIV protease inhibitors on vasomotor function and superoxide anion production in porcine coronary arteries

HIV protease inhibitors (PIs) have been implicated to cause cardiovascular complications. Previous studies demonstrated that the PI ritonavir (RTV) caused endothelial dysfunction in porcine arteries. This study investigated and compared the effects of 5 commonly used PIs on vasomotor function, endothelial nitric oxide synthase (eNOS) expression, and oxidative stress in porcine coronary arteries. Vessel rings were incubated with 15 microM of RTV, amprenavir (APV), saquinavir (SQV), indinavir (IDV), or nelfinavir (NFV) for 24 hours. Vasomotor function was studied using a myograph system. The contractility of the rings was significantly reduced for RTV and SQV. In response to bradykinin at 10(-5) M, the endothelium-dependent relaxation was significantly reduced for RTV, APV, and SQV. The eNOS mRNA levels were significantly reduced for RTV, APV, and SQV. Furthermore, the superoxide anion (O(2)(-)) levels of the vessels were significantly increased for RTV and APV. It was found that nitric oxide production was decreased, whereas the level of nitrotyrosine proteins was increased in RTV-treated vessels. Furthermore, antioxidant seleno-L-methionine (SeMet) reversed RTV-induced O(2)(-) production and vasomotor dysfunction. Thus, the HIV PIs RTV, APV, and SQV at 15 microM have more potent in vitro effects on vasomotor dysfunction, eNOS downregulation, and O(2)(-) production than IDV and NFV. The antioxidant SeMet can block these adverse effects of RTV. The results suggest that antioxidant therapy may have applications for controlling PI-associated cardiovascular complications.

Efficacy and tolerability of a nucleoside reverse transcriptase inhibitor-sparing combination of lopinavir/ritonavir and efavirenz in HIV-1-infected patients

BACKGROUND

Recommended antiretroviral regimens include a nucleoside reverse transcriptase inhibitor (NRTI) component. Class cross-resistance and mitochondrial toxicity are recognized as problems with this class of antiretrovirals.

METHODS

In a pilot open-label study, 65 antiretroviral-naive and 21 experienced but nonnucleoside reverse transcriptase inhibitor-naive HIV-1-infected adults were given a combination of lopinavir/ritonavir (533.3/133.3 mg twice daily) and efavirenz (600 mg once daily) for 48 weeks.

RESULTS

At baseline, the mean viral load was 4.84 log10 copies/mL and the mean CD4 count was 311 cells/mm. At week 24, the proportions of patients with a viral load <400 copies/mL were 78% and 93% using an intent-to-treat and on-treatment analysis, respectively. At week 48, proportions were 73% and 97%, respectively. Treatment discontinuation occurred in 21 patients during the 48-week period, with 33% of those attributable to drug-related adverse effects. A viral load >400 copies/mL at week 24 or 48 was associated with nonadherence in 3 patients and virologic failure in 1 patient. After an increase during the first 8 weeks, fasting lipid levels remained stable up to 48 weeks.

CONCLUSION

The lopinavir/ritonavir-efavirenz combination is associated with a high rate of virologic response and should be compared with more classic NRTI-containing regimens in randomized and controlled clinical trials.

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.