Subclinic atherosclerosis and cardiovascular risk factors in HIV-infected children: PERI study

Pulse wave velocity in early-treated children living with perinatal HIV infection is similar to uninfected children

INTRODUCTION

HIV is associated with accelerated cardiovascular disease, due to HIV-associated metabolic abnormalities, antiretroviral therapy (ART), and HIV itself. Carotid-femoral pulse wave velocity (PWV) is the noninvasive gold standard measurement of arterial stiffness, and associated with incident vascular events in adults. It is unclear if arterial stiffness is accelerated in children living with perinatal HIV (CHIV) who initiate ART early in life. We compared the longitudinal trajectory of PWV in CHIV to children unexposed to HIV. A secondary comparison compared HIV exposed uninfected children (CHEU) to unexposed children.

METHODS

Four hundred and sixty-five children (141 CHIV, 160 CHEU, 164 unexposed) previously in the children with HIV early antiretroviral therapy (ART) (CHER) and P1060 trials were followed annually at Tygerberg Children's Hospital, South Africa between 2014 and 2020. CHIV initiated ART in infancy or early childhood, with excellent ART adherence and largely sustained viral suppression. The primary outcome was PWV, measured using the Vicorder system, and evaluated using linear mixed effects models.

RESULTS

Median (interquartile range) age at first PWV measurement was 8.64 (7.7-9.1) years, and median follow-up time 2.9 (1.6-4.0) years. Adjusted analyses showed no significant mean difference in PWV in CHIV and CHEU compared to unexposed [CHIV: 0.101 m/s, 95% confidence interval (CI) -0.012 to 0.214; CHEU: 0.068 m/s, 95% CI -0.047 to 0.183], after adjusting for gender, age, ethnicity, mean arterial pressure, resting average heart rate and family history of cardiovascular disease.

CONCLUSIONS

Early-treated CHIV with sustained viral suppression have similar PWV to unexposed children. Excellent adherence and early ART initiation may protect against cardiovascular disease.

CD4:CD8 Ratio and CD8 Cell Count and Their Prognostic Relevance for Coronary Heart Disease Events and Stroke in Antiretroviral Treated Individuals: The Swiss HIV Cohort Study

INTRODUCTION

HIV infection leads to a persistent expansion of terminally CD8 T cells and CD8 T suppressor cells, a marker of chronic immune activation leading to a low CD4:CD8 ratio that may persist in the presence of potent antiretroviral therapy and regained CD4 helper cells. It remains unclear whether a low CD4:CD8 ratio is associated with cardiovascular diseases.

METHODS

We conducted an observational cohort study to investigate the association of immune depression and activation as characterized by the proxy of the CD4:CD8 ratio on the hazard of coronary heart disease (CHD) and stroke among treated individuals living with HIV, while accounting for viral load and known risk factors for cardiovascular diseases and exposure to abacavir or protease inhibitors. We used Cox proportional hazard models with time-dependent cumulative and lagged exposures to account for time-evolving risk factors and avoid reverse causality.

RESULTS

CD4, CD8, and CD4:CD8 immunological markers were not associated with an increased hazard for CHD. CD8 cell count lagged at 12 months above 1000 cells per μL increased the hazard of stroke, after adjusting for sociodemographics, cardiovascular risk factors, and exposure to specific types of antiretroviral drugs.

CONCLUSIONS

This analysis of treated HIV-positive individuals within a large cohort with long-term follow-up does not provide evidence for a prognostic role of immune dysregulation regarding CHD. However, increased CD8 cell count may be a moderate risk factor for stroke. Early detection and treatment of HIV-positive individuals are crucial for an optimal immune restoration and a limited CD8 cells expansion.

The effect of perinatal HIV and antiretroviral therapy on vascular structure and function in young people: A systematic review and meta-analysis

BACKGROUND AND AIMS

Perinatal HIV infection (PHIV) and prolonged use of antiretroviral therapy (ART) may increase the likelihood of developing subclinical vascular dysfunction at an early age. We conducted a systematic review to assess the effect of PHIV and ART on intima-media thickness (IMT), arterial stiffness and endothelial function in individuals aged 6-25 years.

METHODS

Medline, Embase and Web of Science were searched, and studies screened by two independent reviewers. We performed a meta-analysis on selected studies reporting on IMT.

RESULTS

A total of 680 studies were retrieved from the databases, with 21 studies deemed eligible for qualitative analysis. There were few studies assessing IMT, arterial stiffness and endothelial function. More than half of the studies found either increased IMT, stiffer arteries or impaired endothelial function in PHIV compared to uninfected controls. A minority of the studies reported that the two groups had similar vascular parameters, a conflicting finding. There was a lack of standardisation for IMT assessment and reporting in numerous studies. In a meta-analysis of seven studies with matching methodologies, IMT was higher in PHIV compared to uninfected controls, (mean difference, 0.05 (0.01-0.09; p = 0.01) but heterogeneity between the studies was substantial (I², 96.7%; p < 0.001).

CONCLUSIONS

PHIV may affect vascular structure and function. Existing studies are generally small, often contradictory, and predominantly cross-sectional in design. Further studies are required to understand vascular health in PHIV to identify cardiovascular disease risk and improve interventional strategies aimed at prevention and treatment of early vascular changes in this population.

Atherosclerotic Process in Seroreverter Children and Adolescents Exposed to Fetal Antiretroviral Therapy

BACKGROUND

Human immunodeficiency virus infection is a recognized risk factor for premature atherosclerosis in children and adolescents. However, the atherosclerotic process in uninfected children exposed in utero to the virus and antiretroviral therapy is less clear.

OBJECTIVE

To determine the potential cardiovascular risk associated to this in utero milieu exposition.

MATERIAL AND METHODS

A total of 115 individuals were studied (77 in the sample group and 38 in the controls). Eighteen analytical mediators involved in the atherogenic pathways (metabolic dysregulation, inflammation, and prothrombotic state) were analyzed. The carotid intima-media thickness, which is a subclinical marker of atherosclerosis, was also measured.

RESULTS

No significant statistical differences were identified between the sample and control groups, either in the biochemical or the echographic markers.

CONCLUSION

In utero exposure to the HIV virus and antiretroviral therapy in uninfected children and adolescents is not correlated to accelerated atherosclerosis.

Deciphering Endothelial Dysfunction in the HIV-Infected Population

Cardiovascular disease (CVD), as a possible consequence of endothelial dysfunction, is prevalent among HIV-infected patients despite successful administration of antiretroviral drugs. This warrants the routine clinical assessment of endothelial function in HIV-positive patients to circumvent potential CVD events. Several different non-invasive strategies have been employed to assess endothelial function in clinical research studies yielding inconsistencies among these reports. This review summarises the different techniques used for assessing endothelial function, with a focus on proposed blood-based biomarkers, such as endothelial leukocyte adhesion molecule-1 (E-selectin), soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), von Willebrand factor (vWF), TNF-α, interleukin 6 (IL6) and soluble thrombomodulin (sTM). The identification of suitable blood-based biomarkers, especially those that can be measured using a point-of-care device, would be more applicable in under-resourced countries where the prevalence of HIV is high.

Aerobic fitness and physical activity are inversely associated with body fat, dyslipidemia and inflammatory mediators in children and adolescents living with HIV

This study aimed to investigate if moderate to vigorous physical activity (MVPA) and aerobic fitness are associated with cardiovascular risk factors in HIV+ children and adolescents. Sixty-five children and adolescents (8 to 15 years) provided minutes of MVPA measured by accelerometers and peak oxygen uptake (peak VO₂) by breath-by-breath respiratory exchange. Cardiovascular risk factors were characterized by body fat, blood pressure, total cholesterol, HDL-c, LDL-c, triglycerides, glucose, insulin, C-reactive protein (CRP), interleukin (IL)-6, tumor necrosis factor-alpha (TNF-α) and carotid intima-media thickness. Results indicated that higher MVPA was associated with lower values of total (β =  -3.566) and trunk body fat (β = -3.495), total cholesterol (β = -0.112) and LDL-c (β = -0.830). Likewise, higher peak VO₂ was associated with lower total (β = -0.629) and trunk body fat values (β = -0.592) and levels of CRP (β = -0.059). The physically active participants had lower total cholesterol (-24.4 mg.dL^-1) and LDL-c (-20.1 mg.dL^-1) compared to participants judged to be insufficiently active. Moreover, participants with satisfactory peak VO₂ showed lower total (-4.1%) and trunk (-4.3%) body fat, CRP (-2.3 mg.L^-1), IL-6 (-2.4 pg.mL^-1) and TNF-α (-1.0 pg.mL^-1) compared to low peak VO₂ peers. High levels of MVPA and aerobic fitness may prevent developing of cardiovascular risk factors in children and adolescents HIV+.

Patterns of Growth, Body Composition, and Lipid Profiles in a South African Cohort of Human Immunodeficiency Virus-Infected and Uninfected Children: A Cross-Sectional Study

BACKGROUND

Prior research in sub-Saharan Africa reports dyslipidemia in perinatally human immunodeficiency virus (HIV)-infected children receiving ritonavir-boosted lopinavir (LPV/r) compared with efavirenz; however, interpretation of findings is limited by lack of comparison data from HIV-uninfected children.

METHODS

We conducted a cross-sectional analysis of lipid profiles and growth within a larger longitudinal cohort study of perinatally HIV-infected and HIV-uninfected children aged 4-9 years in Johannesburg, South Africa. At enrollment, anthropometrics, viral load, CD4, total cholesterol (TC), high-density lipoprotein, low-density lipoprotein (LDL), and triglycerides were measured. Weight-for-age Z-score (WAZ), height-for-age Z-score (HAZ), and body mass index-for-age Z-score (BAZ) were calculated. United States pediatric thresholds for dyslipidemia were used.

RESULTS

Five hundred fifty-three HIV-infected and 300 HIV-uninfected children (median age 6.9 years) of similar demographic characteristics were enrolled. Of the HIV-infected children, 94.8% were on combination antiretroviral therapy (cART) (65.4% on LPV/r- and 28.6% on efavirenz-based regimens). Among the treated, 94.3% had a viral load <200 copies/mL. Median CD4% was 34.4. The HIV-infected children had lower mean WAZ (-0.7 vs -0.3, P < .01) and HAZ (-1.1 vs -0.7, P < .01) compared with HIV-uninfected children. A lower proportion of HIV-infected children were overweight (BAZ >1) compared with HIV-uninfected children (14.4% vs 21.7%, P = .04). Whether on LPV/r or efavirenz, a higher proportion of HIV-infected children had borderline/elevated TC or abnormal triglycerides than HIV-uninfected children, although a higher proportion of those on LPV/r had borderline/elevated TC, borderline/elevated LDL, or abnormal triglycerides than those on efavirenz.

CONCLUSIONS

In a South African cohort of HIV-infected children and population-appropriate HIV-uninfected children, unfavorable alterations in lipid profiles were detected in HIV-infected children regardless of treatment regimen compared with HIV-uninfected children. The HIV-infected children were of smaller size than HIV-uninfected children, but there was a high prevalence of overweight in both groups. Strategies for optimizing growth and early life management of lipid alterations may be warranted.

Dyslipidemia, chronic inflammation, and subclinical atherosclerosis in children and adolescents infected with HIV: The PositHIVe Health Study

HIV-infected children and adolescents may be at risk for cardiovascular disease due to chronic inflammation and exacerbation of risk factors. The aim of this study was as follows: 1) compare cardiovascular risk factors, chronic inflammation, and carotid intima-media thickness (IMTc) between the HIV and control groups; 2) determine the association of HIV and antiretroviral (ART) regimens with cardiovascular risk factors, chronic inflammation, and IMTc; and 3) identify variables associated with elevated IMTc. Cross-sectional analysis of 130 children and adolescents, 8-15 years of age, divided into HIV-infected (n = 65) and healthy control (n = 65) participants. Body fat, blood pressure, glycemia, insulin, and glycated hemoglobin, total cholesterol and fractions (LDL-C and HDL-C), triglycerides, C-reactive protein (CRP), interleukin (IL)-6, tumor necrosis factor-alpha (TNF-α), and the IMTc were measured. The results showed HIV-infected children and adolescents had higher levels of glycemia (87.9 vs. 75.9 mg.dL-1, p< 0.001), LDL-c (94.7 vs. 79.5 mg.dL-1, p = 0.010), triglycerides (101.2 vs. 61.6 mg.dL-1, p< 0.001), CRP (1.6 vs. 1.0 mg.L-1, p = 0.007), IL-6 (1.42 vs. 0.01 pg.mL-1, p< 0.001), TNF-α (0.49 vs. 0.01 pg.mL-1, p< 0.001), mean IMTc (0.526 vs. 0.499 mm, p = 0.009), and lower HDL-c (53.7 vs. 69.4 mg.dL-1, p< 0.001) compared to controls. Systolic blood pressure (β = 0.006, p = 0.004) and TNF-α (β = -0.033, p = 0.029) accounted for 16% of IMTc variability in HIV-infected children and adolescents. In patients using protease inhibitors-based ART, male gender (β = -0.186, p = 0.008), trunk body fat (β = -0.011, p = 0.006), glucose (β = 0.005, p = 0.046), and IL-6 (β = 0.017, p = 0.039) accounted for 28% of IMTc variability. HIV-infected children and adolescents may be at risk for premature atherosclerosis due to chronic inflammation and dyslipidemia. Interventions with the potential to improve lipid profile, mitigate inflammation, and reduce cardiovascular risk are needed.

Hepatic, Renal, Hematologic, and Inflammatory Markers in HIV-Infected Children on Long-term Suppressive Antiretroviral Therapy

BACKGROUND

Data on long-term toxicity of antiretroviral therapy (ART) in HIV-infected children are sparse. PENPACT-1 was an open-label trial in which HIV-infected children were assigned randomly to receive protease inhibitor (PI)- or nonnucleoside reverse-transcriptase inhibitor (NNRTI)-based ART.

METHODS

We examined changes in clinical, immunologic, and inflammatory markers from baseline to year 4 in the subset of children in the PENPACT-1 study who experienced viral suppression between week 24 and year 4 of ART. Liver enzyme, creatinine, and cholesterol levels and hematologic parameters were assessed during the trial. Cystatin C, high-sensitivity C-reactive protein (hs-CRP), interleukin 6 (IL-6), d-dimer, and soluble CD14 (sCD14) were assayed from cryopreserved specimens.

RESULTS

Ninety-nine children (52 on PI-based and 47 on NNRTI-based ART) met inclusion criteria. The median age at initiation of ART was 6.5 years (interquartile range [IQR], 3.7-13.4 years), and 22% were aged <3 years at ART initiation; 56% of the PI-treated children received lopinavir/ritonavir, and 70% of NNRTI-treated children received efavirenz initially. We found no evidence of significant clinical toxicity in either group; growth, liver, kidney, and hematologic parameters either remained unchanged or improved between baseline and year 4. Total cholesterol levels increased modestly, but no difference between the groups was found. IL-6 and hs-CRP levels decreased more after 4 years in the NNRTI-based ART group. The median change in IL-6 level was -0.35 pg/ml in the PI-based ART group and -1.0 in the NNRTI-based ART group (P = .05), and the median change in hs-CRP level was 0.25 µg/ml in the PI-based ART group and -0.95 µg/ml in the NNRTI-based ART group (P = .005).

CONCLUSION

These results support the safety of prolonged ART use in HIV-infected children and suggest that suppressive NNRTI-based regimens can be associated with lower levels of systemic inflammation.

Are traditional body fat equations and anthropometry valid to estimate body fat in children and adolescents living with HIV?

The aim of this study was to assess the validity of traditional anthropometric equations and to develop predictive equations of total body and trunk fat for children and adolescents living with HIV based on anthropometric measurements. Forty-eight children and adolescents of both sexes (24 boys) aged 7-17 years, living in Santa Catarina, Brazil, participated in the study. Dual-energy X-ray absorptiometry was used as the reference method to evaluate total body and trunk fat. Height, body weight, circumferences and triceps, subscapular, abdominal and calf skinfolds were measured. The traditional equations of Lohman and Slaughter were used to estimate body fat. Multiple regression models were fitted to predict total body fat (Model 1) and trunk fat (Model 2) using a backward selection procedure. Model 1 had an R2=0.85 and a standard error of the estimate of 1.43. Model 2 had an R2=0.80 and standard error of the estimate=0.49. The traditional equations of Lohman and Slaughter showed poor performance in estimating body fat in children and adolescents living with HIV. The prediction models using anthropometry provided reliable estimates and can be used by clinicians and healthcare professionals to monitor total body and trunk fat in children and adolescents living with HIV.

Safety and Efficacy of Atorvastatin in Human Immunodeficiency Virus-infected Children, Adolescents and Young Adults With Hyperlipidemia

BACKGROUND

Human immunodeficiency virus (HIV)-infected children receiving antiretroviral therapy (ART) have increased prevalence of hyperlipidemia and risk factors for cardiovascular disease. No studies have investigated the efficacy and safety of statins in this population.

METHODS

HIV-infected youth 10 to <24 years of age on stable ART with low-density lipoprotein cholesterol (LDL-C) ≥130 mg/dL for ≥6 months initiated atorvastatin 10 mg once daily. Atorvastatin was increased to 20 mg if LDL-C efficacy criteria (LDL-C < 110 mg/dL or decreased ≥30% from baseline) were not met at week 4. Primary outcomes were safety and efficacy.

RESULTS

Twenty-eight youth initiated atorvastatin; 7 were 10-15 years and 21 were 15-24 years. Mean baseline LDL-C was 161 mg/dL (standard deviation 19 mg/dL). Efficacy criteria were met at week 4 by 17 of 27 (63%) participants. Atorvastatin was increased to 20 mg in 10 participants. Mean LDL-C decreased from baseline by 30% (90% confidence interval: 26%, 35%) at week 4, 28% (90% confidence interval: 23%, 33%) at week 24 and 26% (90% confidence interval: 20%, 33%) at week 48. LDL-C was less than 110 mg/dL in 44% at week 4, 42% at week 12 and 46% at weeks 24 and 48. Total cholesterol, non high-density lipoprotein (non-HDL)-C and apolipoprotein B decreased significantly, but IL-6 and high-sensitivity C-reactive protein did not. Two participants in the younger age group discontinued study for toxicities possibly related to atorvastatin.

CONCLUSIONS

Atorvastatin lowered total cholesterol, LDL-C, non HDL-C and apolipoprotein B in HIV-infected youth with ART-associated hyperlipidemia. Atorvastatin could be considered for HIV-infected children with hyperlipidemia, but safety monitoring is important particularly in younger children.

Prediction of Areal Bone Mineral Density and Bone Mineral Content in Children and Adolescents Living With HIV Based on Anthropometric Variables

Children and adolescents living with HIV have low bone mass for age. There are reliable and accurate methods for evaluation of bone mass, however, alternative methods are necessary, especially, for application in limited-resource scenarios. Anthropometry is a noninvasive and low cost method that can predict bone mass in healthy youths. The aim of the study was to develop predictive equations for bone mineral content and bone mineral density in children and adolescents living with HIV based on anthropometric variables. Forty-eight children and adolescents of both sexes (24 females) from 7 to 17 years, living in greater Florianopolis area, Santa Catarina, Brazil, who were under clinical follow-up at "Hospital Infantil Joana de Gusmão", participated in the study. Dual-energy X-ray absorptiometry was used to evaluate whole-body bone mineral content (BMC) and areal bone mineral density (aBMD). Height, body weight, bone diameters, arm circumference, and triceps skinfold were measured and the body mass index and arm muscle area were calculated. Multiple regression models were fitted to predict BMC and aBMD, using backward selection (p ≥ 0.05). Two predictive models with high R² values (84%-94%) were developed. Model 1 to estimate aBMD [Y = -0.1450124 + (height × 0.0033807) + (age × 0.0146381) + (body mass index × 0.0158838) + (skin color × 0.0421068)], and model 2 to estimate BMC [Y = 1095.1 + (body weight × 45.66973) + (age × 31.36516) + (arm circumference × -53.27204) + (femoral diameter × -9.594018)].The predictive models using anthropometry provided reliable estimates and can be useful to monitor aBMD and BMC in children and adolescents living with human immunodeficiency virus where limited resources are available.

Clinical outcomes and risk factors for posterior reversible encephalopathy syndrome in systemic lupus erythematosus: a multicentric case-control study

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a well-known but rare complication in patients (<1%) with systemic lupus erythematosus (SLE). However, current epidemiological data are quite scant. The aim of the present study was to describe potentially unrecognised risk factors.

PATIENTS AND METHODS

We performed a multicentre, retrospective case-control study in Mexico between 1999 and 2014. We included a total of 168 patients who accounted for 77 episodes of PRES, as follows: SLE/PRES, 43 patients with 48 episodes; SLE without PRES, 96 patients; and PRES without SLE, 29 patients. SLE diagnosis was considered when patients fulfilled ≥4 American College of Rheumatology criteria. PRES was defined by reversible neurological manifestations and MRI changes.

RESULTS

Patients with SLE/PRES were younger, presented with seizures as the most common manifestation (81%) and 18% had the typical occipital MRI finding. Hypertension (OR=16.3, 95% CI 4.03 to 65.8), renal dysfunction (OR=6.65, 95% CI 1.24 to 35.6), lymphopenia (OR=5.76, 95% CI 1.36 to 24.4), Systemic Lupus Erythematosus Activity Index ≥ 6 points (OR=1.11, 95% CI 1.01 to 1.22) and younger age (OR=0.86, 95% CI 0.81 to 0.91, p<0.001) were independent risk factors for development of PRES in SLE. Furthermore, dyslipidemia also characterised the association between PRES and SLE (OR=10.6, 95% CI 1.17 to 96.4).

CONCLUSIONS

This is the largest reported series of patients with SLE and PRES. We were able to corroborate the known risk factors for of PRES, and found two previously undescribed factors (lymphopenia and dyslipidemia), which suggests that endothelial dysfunction is a key element in PRES pathogenesis in lupus patients.

Effects of paediatric HIV infection on childhood vasculature

AIMS

Human immunodeficiency virus (HIV) infection may alter childhood vascular properties and influence future cardiovascular risk. Whether vascular changes are associated with HIV infection per se or antiretroviral therapy (ART) is unknown. We investigated the effects of ART-naive or ART-exposed HIV infection in children on childhood vascular characteristics.

METHODS AND RESULTS

We performed vascular ultrasound to measure carotid intima media thickness (cIMT), distensibility, and elastic modulus on 114 children with vertically acquired HIV infection (56 ART-naive, 58 ART treated) and 51 healthy children in Jakarta, Indonesia. Children also underwent clinical and blood examinations. We used general linear modelling to estimate associations between HIV infection/treatment status and vascular characteristics with adjustment for confounders or possible mediators. Vascular measurements were successful in 42 ART-naive HIV-infected [median age 4.0 years (min 0.4-max 11.5)]; 53 ART-treated HIV infected [5.7 years (0.6-12.2), median ART duration 2.4 years (0.1-9.9)]; and 48 healthy children, 6.5 years (2.4-14.0). The ART-naive HIV infected had thicker cIMT (difference 70.4 µm, 95% CI 32.1-108.7, P < 0.001), adjusted for age, sex, socioeconomic status, parental smoking, body mass index, systolic and diastolic blood pressure, LDL cholesterol, and HbA1c. Addition of high-sensitivity C-reactive protein (hs-CRP) level to the model did not affect the results (71.6 µm, 31.9-111.2, P = 0.001). The ART-exposed children had similar cIMT dimensions to healthy children. Distensibility was not significantly different between HIV infected, either ART-naive or -exposed, and healthy children, but adjusted analysis including only ART-exposed children with controlled HIV (CD4+ ≥200/mm³ or CD4+ ≥15%) showed that the ART-exposed had an increased elastic modulus (difference 37.9 kPa, 95% CI 6.5-69.3, P = 0.02), and following adjustment for hs-CRP (35.5 kPa, 95% CI 4.2-66.8, P = 0.03).

CONCLUSION

ART-naive HIV infection in children is associated with increased cIMT. Children with ART-controlled HIV may have increased arterial stiffness, although further confirmation is required.

Metabolic and renal adverse effects of antiretroviral therapy in HIV-infected children and adolescents

Worldwide, the benefits of combined antiretroviral (ARV) therapy in morbidity and mortality due to perinatally acquired human immunodeficiency virus infection are beyond question and outweigh the toxicity these drugs have been associated with in HIV-infected children and adolescents to date. In puberty, abnormal body fat distribution is stigmatizating and leads to low adherence to ARV treatment. The other metabolic comorbidities (mitochondrial toxicity, dyslipidemias, insulin resistance and low bone mineral density) and renal toxicity, albeit nonsymptomatic in most children, are increasingly being reported and potentially put this population at risk for early cardiovascular or cerebrovascular atherosclerotic disease, diabetes, pathologic fractures or premature renal failure in the third and fourth decades of life. Evidence from available studies is limited because of methodological limitations and also because of several HIV-unrelated factors influencing, to some degree, the development of these conditions. Current recommendations for the prevention, diagnosis, monitoring and treatment of metabolic and renal adverse effects in HIV-children and adolescents are based on adult studies, observational pediatric studies and experts' consensus. Healthy lifestyle habits (regarding diet, exercise and refraining from toxic substances) and wise use of ARV options are the only preventive tools for the majority of patients. Should abnormal findings arise, switches in one or more ARV drugs have proved useful. Specific therapies are also available for some of these comorbidities, although the experience in the pediatric age is still very scarce. We aim to summarize the epidemiological, clinical and therapeutic aspects of metabolic and renal adverse effects in vertically HIV-infected children and adolescents.

Effect of reducing the paediatric stavudine dose by half: a physiologically-based pharmacokinetic model

Owing to significant dose-related toxicity, the adult stavudine dose was reduced in 2007. The paediatric dose, however, has not been reduced. Although the intended paediatric dose is 1 mg/kg twice daily (b.i.d.), the current weight-band dosing approach results in a mean actual dose of 1.23±0.47 mg/kg. Both efficacy and mitochondrial toxicity depend on the concentration of the intracellular metabolite stavudine triphosphate (d4T-TP). We simulated the effect of reducing the paediatric dose to 0.5 mg/kg. A physiologically-based pharmacokinetic model consisting of 13 tissue compartments plus a full ADAM model was used to describe the elimination of stavudine. The volume of distribution at steady-state and apparent oral clearance were simulated and the resulting AUC profile was compared with literature data in adult and paediatric populations. A biochemical reaction model was utilised to simulate intracellular d4T-TP levels for both the standard and proposed reduced paediatric doses. Simulated and observed exposure after oral dosing showed adequate agreement. Mean steady-state d4T-TP for 1.23 mg/kg b.i.d. was 27.9 (90% CI 27.0-28.9) fmol/10(6) cells, 25% higher than that achieved by the 40 mg adult dose. The 0.5 mg/kg dose resulted in d4T-TP of 13.2 (12.7-13.7) fmol/10(6) cells, slightly higher than the adult dose of 20 mg b.i.d. [11.5 (11.2-11.9) fmol/10(6) cells], which has excellent antiviral efficacy and substantially less toxicity. Current paediatric dosing may result in even higher d4T-TP than the original 40 mg adult dose. Halving the paediatric dose would significantly reduce the risk of mitochondrial toxicity without compromising antiviral efficacy.

Echocardiography and carotid intima-media thickness among asymptomatic HIV-infected adolescents in Thailand

OBJECTIVES

To evaluate the carotid intima-media thickness (cIMT) in perinatally HIV-infected adolescents and factors associated with cardiovascular abnormalities.

DESIGNS

A cross-sectional study was conducted in perinatally HIV-infected adolescents who had no known cardiovascular condition and healthy controls.

METHODS

Transthoracic echocardiogram and cIMT measurements were taken by pediatric cardiologists. Serum lipid profiles, high-sensitivity C-reactive protein and N-terminal pro-brain natriuretic peptide were measured.

RESULTS

Hundred HIV-infected and 50 healthy adolescents were enrolled. Echocardiograms revealed overall normal systolic function (median left-ventricular ejection fraction 66 vs. 66%; P = 0.825). The mean overall cIMTs of common carotid arteries and internal carotid arteries were not different between the groups (0.373 vs. 0.371; P = 0.744). Among the HIV-infected adolescents, those who had been receiving protease inhibitor-containing regimens had an increased cIMT (0.364 vs. 0.381 mm; P = 0.009). Hypertriglyceridemia was found in 52% of those who had received protease inhibitors for more than 6 months, but only in 21% of those who had never received protease inhibitors (odds ratio 4.0, 95% confidence interval 1.6-9.7, P = 0.002). Current HIV-RNA, CD4, BMI, sex, cholesterol and low-density lipoprotein-cholesterol were not associated with increased cIMT. Serum high-sensitivity C-reactive protein and N-terminal pro-brain natriuretic peptide were not different between the groups and not associated with cardiac abnormalities.

CONCLUSIONS

Perinatally HIV-infected adolescents had comparable myocardial function and similar cIMT measurements to healthy adolescents. However, hypertriglyceridemia and increased cIMT were found in HIV-infected adolescents receiving protease inhibitor-based regimens. Longer-term follow-up is needed to evaluate HIV-associated cardiovascular disease risk in this population.

Subclinical atherosclerosis and markers of immune activation in HIV-infected children and adolescents: the CaroVIH Study

BACKGROUND

HIV-infected adults display increased cardiovascular disease, probably driven by inflammation and immune activation. These relationships have not been addressed in vertically HIV-infected children and adolescents, a population at very high risk for long-term non-AIDS complications.

METHODS

Carotid intima media thickness (IMT) was measured in a cohort of HIV-infected children and adolescents and healthy controls. C-reactive protein and markers of immune activation (CD38⁺HLA-DR⁺) and immune senescence (CD28⁻CD57⁺) were determined.

RESULTS

One hundred fifty HIV-infected patients and 150 controls were included, 64.8% female. IMT was thicker in HIV-infected patients (0.434 mm ± 0.025 vs. 0.424 mm ± 0.018, P < 0.001). After adjustment by age, sex, body mass index, and smoking status, HIV infection was independently associated with thicker IMT (odds ratio, 2.28; 95% confidence interval: 1.25 to 4.13; P = 0.007). Among HIV-related variables, a low CD4 nadir was related to an increased IMT. Although HIV-infected subjects presented higher frequencies of activated CD4⁺ and CD8⁺ T cells (P = 0.002 and P = 0.087, respectively), no relation was found between IMT and inflammation, immune activation, or senescence.

CONCLUSIONS

Structural changes of the vasculature present early in vertically HIV-infected subjects as well as immune activation and senescence. These patients should be carefully monitored for the prompt detection and early treatment of cardiovascular disease.

Neurologic complications of pediatric human immunodeficiency virus: implications for clinical practice and management challenges in the African setting

Approximately 3.4 million children worldwide are affected with human immunodeficiency virus (HIV)/AIDS with more than 90% of them residing in sub-Saharan Africa, according to the World Health Organization. A significant proportion of the children eligible for treatment with antiretroviral therapy are not currently receiving it. Neurologic manifestations of HIV are common in both adults and children. There is a large spectrum of neurologic conditions that may be caused by the virus; however, early invasion of the central nervous system by the virus, affecting the developing fetal and infant brain, is believed to result in the most common primary HIV-related central nervous system complication, HIV encephalopathy. This article summarizes the spectrum of neuro-HIV in children, focuses on the neurocognitive and behavioral sequelae, reviews the effects of treatment on the primary neurologic effects of the disease, and discusses the specific challenges of identifying and managing these problems in resource-limited contexts, such as those found on the African continent.

Dietary intake and nutritional status of HIV-1-infected children and adolescents in Florianopolis, Brazil

This cross-sectional study aimed to investigate the nutritional status and dietary intake of HIV-infected children and adolescents and the relationship between nutritional status and dietary intake and CD4(+) T-cell count and viral load. The sample was composed of 49 subjects aged 7-17 years and living in Florianópolis, Brazil. Nutritional status was assessed by height-for-age and body mass index-for-age. Dietary intake was assessed by a food frequency questionnaire. Spearman correlations and multiple linear regressions were used to determine the relationship between energy, nutrient intake and body mass index-for-age and CD4(+) T-cell count and viral load. The mean body mass index-for-age and height-for-age values were -0.26 ± 0.86 and -0.56 ± 0.92, respectively. The energy intake was 50.8% above the estimated energy requirement and inadequate intake of polyunsaturated fat, cholesterol, fibre, calcium and vitamin C was present in 100%, 57.1%, 40.8%, 61.2% and 26.5% of the sample, respectively. Multiple linear regression analyses revealed that energy intake was correlated with CD4+ T-cell count (r = 0.33; p = 0.028) and viral load (r = -0.35; p = 0.019). These data showed low body mass index-for-age and height-for-age z-scores, high energy intake and inadequate intake of important nutrients for immune function, growth and control of chronic diseases. A lower energy intake was correlated with viral suppression and immune preservation.

The relationship between vitamin D status and HIV-related complications in HIV-infected children and young adults

BACKGROUND

In HIV-infected adults, we and others have shown that vitamin D deficiency is independently associated with increased carotid intima-media thickness (cIMT), a surrogate marker for cardiovascular disease (CVD). This study explored for the first time the relationship between vitamin D and CVD risk in HIV-infected youth.

METHODS

This is a cross-sectional assessment of cIMT, inflammation, metabolic markers and vitamin D status in HIV-infected youth and healthy controls. We measured serum 25-hydroxyvitamin D (25(OH)D), fasting lipids, insulin, glucose, inflammatory markers and cIMT.

RESULTS

Thirty HIV-infected subjects and 31 controls were included. Among HIV-infected subjects, median age was 11 years (37% males; 73% black; similar to controls). HIV-infected subjects' mean (standard deviation) serum 25(OH)D was 24 (35) ng/mL; 70% had 25(OH)D<20 ng/mL (deficient), 23% between 20-30 ng/mL (insufficient) and 7%>30 ng/mL (sufficient); proportions were similar to controls (P=0.17). After adjusting for season, sex and race, there was no difference in serum 25(OH)D between groups (P=0.11). Serum 25(OH)D was not significantly correlated with cIMT, inflammatory markers or lipids. Serum 25(OH)D was negatively correlated with body mass index, insulin resistance, HIV duration, and cumulative use of antiretroviral therapy, non- and nucleoside reverse transcriptase inhibitors.

CONCLUSIONS

Most HIV-infected youth have vitamin D deficiency or insufficiency. Despite no direct association between serum 25(OH)D and cIMT, there were notable associations with some CVD risk factors, particularly inverse correlation with insulin resistance. Studies are needed to determine whether CVD risk, including insulin resistance, could be improved with vitamin D supplementation.

Long-term changes in carotid intima-media thickness among HIV-infected children and young adults

BACKGROUND

HIV-infected patients are at increased risk of cardiovascular disease (CVD). This study assessed long-term changes in carotid intima-media thickness (IMT) as a surrogate marker for CVD risk in HIV-infected children and young adults.

METHODS

This was a longitudinal, observational study comparing carotid IMT in HIV-infected subjects who were 2-21 years old to matched controls over 144 weeks.

RESULTS

A total of 34 HIV-infected subjects and 29 controls were included in the analyses. Among the HIV-infected group, median age was 10 years, 74% were black, and 65% were female. Overall, 91% were perinatally-infected with 82% on antiretroviral therapy and a median CD4(+) T-cell count of 681 cells/mm(3). At baseline, HIV-infected subjects had increased internal carotid artery (ICA) and common carotid artery (CCA) IMT (ICA, HIV-infected 0.90 mm versus controls 0.73 mm; P<0.01; CCA, HIV-infected 1.00 mm versus controls 0.90 mm; P=0.02). Relatively large changes in ICA and CCA IMT were seen from year to year in both groups. However, by week 144, there were no net changes in ICA or CCA IMT within the HIV-infected group. In the controls, CCA increased 0.1 mm and ICA increased 0.17 mm from baseline to week 144. ICA and CCA IMT were similar between groups by 144 weeks.

CONCLUSIONS

Despite variations from year to year in carotid IMT in HIV-infected children and healthy controls, likely due to arterial growth and/or luminal diameter change, little or no net change occurred in carotid IMT over the entire 144-week study period. This suggests that only small net changes occur over time in HIV-infected children despite an increased long-term risk of CVD.

Metabolic complications and treatment of perinatally HIV-infected children and adolescents

The benefits of long-term antiretroviral therapy (ART) are recognized all over the world with infected children maturing into adults and HIV infection becoming a chronic illness. However, the improved survival is associated with serious metabolic complications, including lipodystrophy (LD), dyslipidemia, insulin resistance, lactic acidosis and bone loss. In addition, the dyslipidemia mainly seen with protease inhibitors may increase the risk of cardiovascular disease in adulthood and potentially in children as they mature into adults. Nucleoside reverse transcriptase inhibitors, particularly stavudine, zidovudine and didanosine are linked to development of LD and lactic acidosis. Perinatally infected children initiate ART early in life; they require lifelong therapy with multiple drug regimens leading to varying toxicities, all potentially impacting their quality of life. LD has a significant impact on the mental health of older children and adolescents leading to poor self-image, depression and subsequent poor adherence to therapy. Reduced bone mineral density (BMD) is reported in both adults and children on ART with the potential for children to develop more serious bone complications than adults due to their rapid growth spurts and puberty. The role of vitamin D in HIV-associated osteopenia and osteoporosis is not clear and needs further study. Most resource-limited settings are unable to monitor lipid profiles or BMD, exposing infected children and adolescents to on-going toxicities with unclear long-term consequences. Improved interventions are urgently needed to prevent and manage these metabolic complications. Longitudinal cohort studies in this area should remain a priority, particularly in resource-limited settings where the majority of infected children reside.

Replication of RYR3 gene polymorphism association with cIMT among HIV-infected whites

To replicate the association of variants in RYR3 gene with common carotid intima-media thickness (cIMT), a surrogate marker of atherosclerosis, we genotyped single nucleotide polymorphisms (SNPs) rs2229116 and rs7177922 in a sub-population of 244 HIV-positive and HIV-negative men. SNP rs2229116 was associated with common cIMT in HIV infected white men after adjusting for age and use of stavudine (d4T). The association was more evident at younger ages and decreased among older individuals.

Is arterial stiffness in HIV-infected individuals associated with HIV-related factors?

We investigated the association between pulse wave velocity (PWV) and HIV infection, antiretroviral treatment-related characteristics, viral load, immune status, and metabolic changes in a cross-sectional study nested in a cohort of HIV/AIDS patients who have been followed for metabolic and cardiovascular changes since 2007. The study included patients recruited from the cohort (N = 261) and a comparison group (N = 82) of uninfected individuals, all enrolled from April to November 2009. Aortic stiffness was estimated using the carotid-femoral PWV (Complior-Artech, Paris, France). The groups were similar with respect to age, metabolic syndrome, diabetes mellitus, Framingham score, and use of antihypertensive and hypolipidemic medications. Hypertension was more frequent among the controls. Individuals with HIV had higher triglyceride, glucose and HDL cholesterol levels. Among individuals with HIV/AIDS, those with a nadir CD4⁺ T-cell count <200 cells/mm³ had a higher PWV (P = 0.01). There was no statistically significant difference when subjects were stratified by gender. Heart rate, age, male gender, and blood pressure were independently correlated with PWV. Nadir CD4⁺ T-cell count did not remain in the final model. There was no significance difference in PWV between HIV-infected individuals and uninfected controls. PWV was correlated with age, gender, and blood pressure across the entire population and among those infected with HIV. We recommend cohort studies to further explore the association between inflammation related to HIV infection and/or immune reconstitution and antiretroviral use and PWV.

Previous gestational diabetes is independently associated with increased carotid intima-media thickness, similarly to metabolic syndrome - a case control study

Background

Women with previous gestational diabetes mellitus (pGDM) face a higher risk of developing type 2 diabetes and, consequently, a higher cardiovascular risk. This study aimed to compare the carotid intima-media thickness (cIMT) from young women with pGDM to those with metabolic syndrome (MS) and to healthy controls (CG) to verify whether a past history of pGDM could be independently associated with increased cIMT.

Methods

This is a cross-sectional study performed in two academic referral centers. Seventy-nine women with pGDM, 30 women with MS, and 60 CG aged between 18 and 47 years were enrolled. They all underwent physical examination and had blood glucose, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol (LDLc), and triglycerides determined. The cIMT was measured by ultrasound in several carotid segments. The primary endpoint was cIMT and clinically relevant parameters included as predictors were: age, systolic blood pressure, waist, BMI, total cholesterol, LDLc, triglycerides, fasting glucose, previous history of GDM as a whole group, previous history of GDM without MS, presence of DM, presence of MS, and parity.

Results

cIMT was significantly higher in pGDM when compared to CG in all sites of measurements (P < 0.05) except for the right common carotid. The pGDM women showed similar cIMT measurements to MS in all sites of measurements, except for the left carotid bifurcation, where it was significantly higher than MS (P < 0.001). In a multivariate analysis which included classical cardiovascular risk factors and was adjusted for confounders, pGDM was shown to be independently associated with increased composite cIMT (P < 0.01). The pGDM without risk factors further showed similar cIMT to MS (P > 0.05) and an increased cIMT when compared to controls (P < 0.05).

Conclusions

Previous GDM was independently associated with increased composite cIMT in this young population, similarly to those with MS and regardless the presence of established cardiovascular risk factors.

Secondary complications and co-infections in the HIV-infected adolescent in the antiretroviral era

PURPOSE OF REVIEW

The number of HIV-infected adolescents is increasing dramatically. With combination antiretroviral therapy, they are expected to live well into adulthood. However, complications are emerging at a higher rate in the HIV-infected population compared to the general population. HIV-infected adolescents are also at a high risk of sexually transmitted co-infections. This article reviews the main secondary complications and co-infections in the HIV-infected adolescent.

RECENT FINDINGS

HIV-infected adolescents are at a high risk of sexually transmitted infections. A careful, age-appropriate and developmentally appropriate inquiry into the individual's sexual behavior to assess risk is paramount, in addition to regular screening at medical visits. Treating co-infections is not only important for HIV-infected individuals, but also limits HIV transmission to others. In addition, monitoring and addressing modifiable secondary risk factors for complications such as renal disease, osteopenia or osteoporosis, and cardiovascular disease are critical, well before the onset of clinically apparent disease. Using antiretroviral therapy to suppress viral replication and inflammation appears to be a promising strategy for decreasing secondary complication risk, and likely overshadows the toxicities associated with the long-term use of certain antiretrovirals.

SUMMARY

Assessing and addressing the risk of secondary complications and co-infections in the HIV-infected adolescent is crucial for optimal length and quality of life.

Assessment and modification of cardiovascular disease risk in the HIV-infected individual

HIV-infected patients are living decades longer than before owing to combination antiretroviral therapy. However, complications are emerging in this population at rates higher than the general population, including cardiovascular disease (CVD). HIV-infected patients have many traditional risk factors that account for a significant part of their increased risk of CVD. However, HIV factors, including complications from antiretroviral therapy and increased inflammation associated with chronic HIV infection, also play a role. Clinicians need to be ever-vigilant to calculate and help attenuate any modifiable CVD risk factors for each HIV-infected individual.

Cardiovascular complications of AIDS

PURPOSE OF REVIEW

The purpose of the present review article is to present the recent data on the cardiovascular complications in patients infected with HIV as well as the preventive strategies to reduce cardiovascular disease in those patients.

RECENT FINDINGS

Individuals infected with HIV frequently demonstrate a metabolic syndrome associated with atherosclerosis and cardiovascular disease. Extensive functional and structural arterial wall changes have been observed in these individuals. It is documented that these vascular changes are closely related to highly active antiretroviral treatment-induced metabolic disorders as well as characteristics of the HIV infection itself. Intensive treatment of vascular dysfunction might be helpful in preventing or retarding the atherosclerotic process in HIV patients.

SUMMARY

Marked changes in arterial function and structure are observed in HIV patients leading to increased cardiovascular morbidity and mortality. Early antiretroviral therapy and aggressive treatment of cardiovascular risk factors might be helpful.

Biomarkers of vascular dysfunction in children infected with human immunodeficiency virus-1

BACKGROUND

: We compared biomarkers of vascular dysfunction among HIV-infected children to a demographically similar group of uninfected children and determined factors associated with these biomarkers.

METHODS AND RESULTS

: We measured several biomarkers of vascular dysfunction: C-reactive protein (CRP), interleukin-6 (IL-6), and monocyte chemoattractant protein -1 (MCP-1) (inflammation); fibrinogen and P-selectin (coagulant dysfunction); soluble intracellular cell adhesion molecule-1 (sICAM), soluble vascular cell adhesion molecule-1 (sVCAM), and E-selectin (endothelial dysfunction); and leptin (metabolic dysfunction). Anthropometry, body composition, CD4%, HIV viral load, and antiretroviral therapy were recorded. Mean age was 14.8 years (106 HIV-infected children) and 12.3 years (55 control children). Sex and body mass index Z scores were similar. Infected children had higher sICAM, sVCAM, MCP-1, IL-6, and fibrinogen levels. E-selectin (P = 0.07), and CRP (P = 0.08) trended to be greater in the HIV group, yet leptin and P-selectin were similar. In multivariable analyses in the HIV-infected children alone, each 1 standard deviation increase in waist to hip ratio was associated with increases in sICAM (17%), MCP-1 (19%), IL6 (18%), and CRP (59%). CD4% was inversely associated with sVCAM, MCP-1, IL6, fibrinogen, and CRP.

CONCLUSIONS

: HIV-infected children have higher levels of biomarkers of vascular dysfunction than healthy children. Risk factors associated with these biomarkers include higher waist to hip ratios and HIV disease severity.

Longitudinal changes in carotid intima-media thickness and cardiovascular risk factors in human immunodeficiency virus-infected children and young adults compared with healthy controls

OBJECTIVES

HIV-infected patients are at increased risk of cardiovascular disease (CVD). This study assessed longitudinal changes in carotid intima-media thickness (cIMT) as a surrogate marker for CVD, and determined the relationship between cIMT and cardiovascular risk factors in HIV infected children/young adults.

METHODS

This was a longitudinal, observational study comparing cIMT,fasting metabolic profile, and C-reactive protein in HIV-infected subjects 2 to 21 years old to matched controls at baseline and 48 weeks.

RESULTS

Thirty-five HIV + subjects and 37 controls were included in the analysis. Among HIV + subjects, the median age was 10 years, body mass index was 18.7 kg/m2, 37% were male, CD4 count was 32%, 77% had HIV-RNA 400 copies/mL, and 86% were on antiretrovirals. At baseline,HIV + had higher lipids and C-reactive protein. HIV-infected had higher internal carotid artery (ICA) and common carotid artery (CCA) IMT (mm)(ICA: HIV + , 0.90; controls, 0.78 [P = 0.01]; CCA: HIV + , 1.00; controls,0.95 [P = 0.05]). At 48 weeks, CD4% increased and low-density lipoprotein decreased in HIV-infected subjects. ICA and CCA median changes for HIV-infected subjects were -0.23 and -0.15 mm, respectively (both P 0.01). In controls, only CCA changed (P = 0.04). Between-group changes were not significant, except when only 31 perinatally infected HIV - subjects and the controls were compared (CCA P = 0.04). In multiple regression analyses of HIV + subjects, antiretroviral therapy duration and CD4% were associated with cIMT changes.

CONCLUSIONS

Higher cIMT was found in HIV-infected subjects than in healthy controls, but at 48 weeks, cIMT was similar between groups. These data suggest that HIV-infected children/young adults are at high risk of CVD, but lipid control, immune restoration, and viral suppression with continuous antiretroviral therapy may prevent its worsening.

Lymphopenia is a risk factor in the progression of carotid intima-media thickness in juvenile-onset systemic lupus erythematosus

OBJECTIVE

To characterize the atherosclerotic risk factors in the progression of subclinical atherosclerosis in patients with juvenile-onset systemic lupus erythematosus (SLE).

METHODS

This was a longitudinal study of 76 patients with juvenile-onset SLE. Carotid arteries were evaluated using ultrasonography at baseline and at followup visits at 6-month intervals over the 6-year study period. Clinical and laboratory parameters, disease activity, treatment, and traditional risk factors for atherosclerosis were evaluated. Data were analyzed using generalized estimating equations.

RESULTS

The mean+/-SD age of the patients at baseline was 15.01+/-3.48 years and the mean+/-SD disease duration was 2.65+/-2.5 years. The mean+/-SD duration of followup was 3.74+/-1.24 years. The mean+/-SD intima-media thickness (IMT) of the common carotid arteries differed significantly between the patient and control (n=38) groups (0.63+/-0.08 mm versus 0.54+/-0.06 mm; P<0.001). The presence of lymphopenia at diagnosis and at baseline and higher levels of serum creatinine and C-reactive protein at baseline were positively associated with progression of carotid IMT (P=0.006, P=0.043, P=0.037, and P=0.049, respectively). In multivariate analysis, only lymphopenia at baseline and at diagnosis were consistently associated with progression of IMT (P=0.012 and P=0.045, respectively).

CONCLUSION

In patients with juvenile-onset SLE, some nontraditional risk factors for the progression of subclinical atherosclerosis were identified. Lymphopenia was the only independent risk factor for the progression of IMT. The pathogenic mechanisms warrant further investigation.

Cardiovascular disease and HIV infection: host, virus, or drugs?

PURPOSE OF REVIEW

With effective antiretroviral therapy, cardiovascular disease has gained importance as a cause of morbidity and mortality in HIV-infected persons. We review the risk of cardiovascular disease in HIV-infected persons compared with that in uninfected persons and discuss the relative contributions of host, HIV, and antiretroviral therapy in the light of current knowledge.

RECENT FINDINGS

The incidence of cardiovascular disease in HIV-infected patients receiving antiretroviral therapy is low. However, the risk of cardiovascular disease increased compared with that in uninfected persons. This fact is substantially due to a higher prevalence of underlying traditional cardiovascular risk factors that are mostly host dependent. HIV may additionally contribute both directly through immune activation and inflammation, and indirectly through immunodeficiency. In a more modest way than that of HIV infection, the type of antiretroviral therapy may also contribute through its impact on metabolic and body fat parameters, and possibly through other factors that are currently unclear.

SUMMARY

Prevention of cardiovascular disease in HIV-infected patients should be standard of care. Traditional risk factors should be investigated and aggressively treated when possible. Antiretroviral therapy should be initiated earlier in patients with high cardiovascular risk. From a purely cardiovascular perspective, the benefits of antiretroviral therapy clearly outweigh any potential risk.