Metabolic and body composition changes after six months of highly active antiretroviral therapy in northern Indian patients

Characterizing blood pressure trajectories in people living with HIV following antiretroviral therapy: A systematic review

OBJECTIVES

The advent of antiretroviral therapy (ART) has reduced AIDS-related morbidity and mortality among people living with HIV (PLWH). Due to increased survival, PLWH have now been found to be at risk of chronic conditions related to ageing, such as cardiovascular disease (CVD). Hypertension is common in PLWH and is a major risk factor for the development of CVD. We conducted a systematic literature review to evaluate the research evidence on longitudinal blood pressure (BP) trajectories following ART initiation in PLWH.

METHODS

We searched the following databases: PubMed, CINHAL, Scopus, and Web of Science (up to 15 March 2021) for peer-reviewed published studies that reported BP trajectories following ART initiation in PLWH. Three reviewers independently screened all studies by title and abstract. We included articles in English, published up to March 2021, that report office BP trajectories in PLWH initiating ART. A total of 10 publications met our inclusion criteria. Eight studies were prospective cohorts and two were retrospective.

RESULTS

Nine out of 10 studies in the literature reported an increase in systolic BP (4.7-10.0 mmHg in studies with a follow-up range of 6 months to 8 years, and 3.0-4.7 mmHg/year in time-averaged studies). In addition, four out of 10 studies reported increases in diastolic BP (2.3-8.0 mmHg for a 6 month to 6.8-year follow-up range and 2.3 mmHg/year).

CONCLUSION

Systolic BP consistently increases while diastolic BP changes are more heterogeneous following ART initiation in PLWH. However, the studies were highly variable with respect to population demographics, ART regimen and duration, and follow-up time. Nevertheless, given the risks of CVD complications, such as stroke, heart failure and myocardial infarction, associated with elevated BP, results highlight the importance of future research in this area. It will be important to better characterize BP trajectories over time, identify the most critical times for interventions to reduce BP, determine the long-term CVD consequences in PLWH with elevated BP, and understand how different ART regimens may or may not influence BP and CVD disease.

A qualitative study exploring perceptions of people living with HIV using antiretroviral therapy on self-management of healthy nutrition and the related healthcare service in Ethiopia

In Ethiopia, undernutrition is a quite common health problem among people living with HIV. Unlike in developed countries, nutritional counseling for people living with HIV has not received much attention. This study aimed to explore the perception of people living with HIV on their dietary practice and the existing health care service in Ethiopia. A phenomenological qualitative study was conducted in two hospitals in southern Ethiopia from March to June 2018. A pre-tested interview guide was prepared in English and translated into the Amharic language. The data were collected using key informant interviews, focus group discussions and observations in the ART clinics by six trained nurses. The data were analyzed thematically. Almost all focus group discussion participants mentioned that a healthy diet for ART patients is very important. The majority of the participants mentioned that they were not satisfied with the counseling service given at the ART clinics. Lack of training for health care professionals on nutritional counseling was also reported as a challenge by the nurses themselves. Nutritional counseling given by health care professionals at the ART clinic was poor. Emphasis should be given to the training of healthcare professionals working in ART clinics on nutritional counseling.

Longitudinal analysis of new-onset non-AIDS-defining diseases among people living with HIV: A real-world observational study

OBJECTIVES

We aimed to analyze the incidence rates of new-onset diabetes, hypertriglyceridemia, hypercholesterolemia, liver injury, and renal injury during antiretroviral therapy (ART) among people living with HIV (PLWH) and determine the associated risk factors.

METHODS

This study included PLWH enrolled from Beijing Ditan Hospital from November 11, 2004, to December 29, 2018. The incidence rates of new-onset diabetes, hypertriglyceridemia, hypercholesterolemia, liver injury, and renal injury were calculated and stratified based on ART regimen, CD4 count, and HIV-RNA. Risk factors were determined using Cox regression analysis.

RESULTS

Overall, 6747 participants were included. Moreover, 4.5%, 43.3%, 25.4%, 11.2%, and 6.2% of patients developed new-onset diabetes, hypertriglyceridemia, hypercholesterolemia, liver injury, and renal injury, respectively, with incidence rates of 1.7, 26.9, 10.2, 3.9, and 5.5 per 100 person-years, respectively. Longitudinally, the incidence rates and percentages of these outcomes were highest in the first year of ART. The percentage of dyslipidemia was significantly higher in protease inhibitor (PI)-based regimen than in non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen. However, the percentage of liver injury was significantly higher in NNRTI-based regimen than in PI-based regimen. In multivariate Cox regression analysis, low CD4 count (<200 cells/µL, adjusted hazard ratio [aHR] = 1.34, 95% confidence interval [CI] 1.15-1.57) and high HIV-RNA (>10⁵ copies/mL, aHR = 1.26, 95% CI 1.08-1.48) were risk factors for hypertriglyceridemia.

CONCLUSIONS

Clinical outcomes, including new-onset diabetes, dyslipidemia, and liver and renal injuries, are common in PLWH. Regular glucose, lipid, liver, and renal function monitoring is required during ART, especially in high-risk patients.

A study of effect of anti-retroviral therapy regimen on metabolic syndrome in people living with HIV/AIDS: Post hoc analysis from a tertiary care hospital in western India

BACKGROUND AND AIMS

Indian guidelines for anti-retroviral therapy (ART) are changing. More patients are now on protease-inhibitor (PI) based therapy. While the association of dyslipidemia with nucleoside reverse transcriptase (NRTI) based regimens is well-reported, the effect of Tenofovir (TDF) or PIs has not been studied in detail in India. This study looks at the impact of ART regimen on Metabolic Syndrome (MetS) in people living with HIV/AIDS (PLHA).

METHODS

This study is a post hoc analysis of a cross-sectional study in ART clinics of a hospital in India between Dec 2016 and Nov 2018. A total of 1208 PLHA on ART were part of this study. Chi square test, Mann-Whitney U test, logistic regression analysis was done.

RESULTS

The prevalence of MetS is 21.3%. This study found TDF based PI regimens had a two fold risk of MetS against patients of HIV on other ART regimens. Also, risk is significantly higher than both TDF based 2NRTI/NNRTI regimens and AZT based PI regimens.

CONCLUSION

Patients on TDF based PIs have a significantly higher prevalence of MetS. This has significance in India which relies heavily on TDF as a backbone of ART and is seeing increased use of PIs.

High Prevalence of AH in HIV Patients on ART, in Bahia, Brazil

INTRODUCTION

The prevalence of arterial hypertension (AH) in HIV-patients is highly variable and its association with antiretroviral therapy (ART) is controversial.

OBJECTIVE

To estimate the prevalence of AH and associated factors in HIV-patients on ART.

METHODS

This cross-sectional study was conducted in HIV-patients attended in a referral center in Salvador, Brazil. We evaluated clinical, socio-demographic and anthropometric data. Student's ttests or Mann-Whitney's and Pearson's chi-square tests were used to compare the groups. Values of p <0.05 were considered significant. The variables that presented a value of p <0.20 were included in a logistic regression model.

RESULTS

We evaluated 196 patients (60.7% male) with a mean age of 46.8 ± 11.7 years and a mean body mass index of 24.9 ± 5.3 kg / m2. The median elapsed time since HIV diagnosis and ART use was 11.8 (4.4 - 18.1) and 7.2 (2.7 - 15.3) years, respectively. The prevalence of AH was 41.8%. For individuals > 50 years old, there was a significant association between the increased abdominal circumference and AH and patients ≤ 50 years old presented significant association between AH and overweight, increased abdominal circumference and number of previous ART regimens. After multivariate analysis, age [OR:1.085; 95% CI 1,039 - 1,133], overweight [OR: 4.205; 95% CI 1,841 - 9,606], family history of AH [OR: 2.938; 95% CI 1,253 - 6.885], increased abdominal circumference [OR: 2.774; 95% CI 1.116 - 6.897] and life-time number of ART regimens used [OR: 3.842; 95% CI 1.307 - 11.299] remained associated with AH.

CONCLUSION

AH was highly prevalent and was associated not only with classical risk factors for arterial hypertension, but also with specific ART regimens.

Changes in body mass index among people living with HIV who are new on highly active antiretroviral therapy: a systematic review and meta-analysis

In the era of highly active antiretroviral therapy (HAART), obesity is increasingly being reported among people living with HIV (PLHIV). In this study, we reviewed published literature on body mass index (BMI) changes among treatment-naïve adult PLHIV who started HAART and remained on treatment for at least six months. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, four databases were searched, and results of included studies were synthesized to describe the BMI trend among PLHIV on treatment. The search generated 4948 studies, of which 30 were included in the qualitative synthesis and 18 were eligible for the meta-analysis. All the studies showed an increase in group BMI. HAART was associated with increase in BMI (pooled effect size [ES] = 1.58 kg/m²; 95% CI: 1.36, 1.81). The heterogeneity among the 18 studies was high (I ² = 85%; p < .01). Subgroup analyses showed pooled ES of 1.54 kg/m² (95% CI: 1.21, 1.87) and 1.63 kg/m² (95% CI: 1.34, 1.91) for studies with follow-up ≤1 year and >1 year, respectively. We conclude that the greatest gain in BMI is in the initial 6-12 months on treatment, with minor gains in the second and subsequent years of treatment.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Magnitude and associated factors of diabetes mellitus and hypertension among adult HIV-positive individuals receiving highly active antiretroviral therapy at Jugal Hospital, Harar, Ethiopia

BACKGROUND

People with HIV infection are at increased risk of noncommunicable diseases (NCDs). Diabetes mellitus (DM) and hypertension are recognized as the major NCDs. Except few findings in general population, there is no well-documented evidence on the magnitude of NCDs and associated factors among HIV-positive patients.

PURPOSE

The aim of this study was to determine the magnitude and associated factors of DM and hypertension among adult HIV-positive subjects receiving highly active antiretroviral therapy (HAART).

METHODS

A hospital-based cross-sectional study was conducted from February to April at Jugal Hospital, Harar, Eastern Ethiopia. Sociodemographic and anthropometric data and blood pressure (BP) were collected by senior clinical nurses. A total of 5 mL of venous blood was collected. Serum glucose and lipid profile were measured using the Autolab 18 clinical chemistry analyzer. Data were analyzed using STATA version 13.

RESULTS

A total of 425 HIV-infected individuals taking HAART of age ranging from 18 to 68 years were included. The prevalence of DM and hypertension were 7.1% (95% CI: 4.9-9.9) and 12.7% (95% CI: 9.8-16.2), respectively. Increased blood triglyceride (adjusted odds ratio [AOR] =4.7, 95% CI: 1.7-13.1), high BP (AOR =3.3, 95% CI: 1.1-9.5), and high baseline body mass index (BMI) (AOR =8.7, 95% CI: 2.4-31.8) were significantly associated with DM. In contrast, raised waist-hip ratio (AOR =4.6, 95% CI: 1.6-13.3), raised blood glucose (AOR =3.5, 95% CI: 1.1-11.4), increased total cholesterol (AOR =3.9, 95% CI: 1.3-11.9), high current BMI (AOR =3.8, 95% CI: 1.5-9.6), drinking alcohol (AOR =3.4, 95% CI: 1.5-8.1), CD4 count <500 cell/mL (AOR =2.7, 95% CI: 1.3-5.6), and longer duration of HAART (AOR =2.3, 95% CI: 1.1-5.1) were significantly associated with hypertension.

CONCLUSION

DM and hypertension were frequent among HIV patients on HAART, and they were linked to the well-known risk factors. Therefore, regular screening and monitoring of DM and hypertension before and after the initiation of HAART is of paramount importance.

Metabolic syndrome among HIV infected patients: A comparative cross sectional study in northwestern Nigeria

INTRODUCTION

The increasing availability of antiretroviral drugs has made HIV-positive patients to live longer, and conditions that are associated with longevity such as metabolic syndrome and other cardiovascular related conditions have become relevant in them. This is less well studied among African populations. Therefore the study aimed at estimating and comparing the prevalence of and associated risk factors for the metabolic syndrome (MS) among African HIV infected patients.

METHOD

In this comparative cross-sectional study, we analyzed the data of 300 participants matched for age and gender who satisfied the inclusion criteria with half of the subjects on HAART, while the other half was HAART naïve. The MS was diagnosed using ATP-III criteria.

RESULTS

The mean age of the patients was 34.8±9.9years. The majority of the patients were females 64%. The prevalence of MS among HAART-exposed patients was found to be 19.3%, while it was 5.3% among HAART naïve patients (p=0.001). Raised triglyceride and elevated blood pressure were the criteria with the highest occurrence among HAART-exposed, 82.8% for each. Advanced age, longer duration of HIV diagnosis and HAART exposure, increased BMI, weight gain after HAART exposure, exposure to PIs and increased mean CD4 cell count were found to be significantly associated with MS (p<0.05). However, only age (OR 4.3, 95% CI 1.6-11.8, p=0.005) and BMI (OR 4.2, 95% CI 1.5-11.9, p=0.007) were found to be independently associated with the development of MS.

CONCLUSION

Exposure to HAART particularly protease inhibitor based regimen increases the risk of MS among HIV-infected patients.

Cardiovascular Disease and Cardiovascular Disease Risk in HIV-Positive Populations in the Asian Region

Introduction:

Cardiovascular diseases (CVD) are becoming more prevalent in HIV-infected populations as they age largely due to improved treatment outcomes. Assessment of CVD risk and CVD risk factors in HIV-positive populations has focused on high income settings, while there are limited studies evaluating CVD in HIV-positive populations in the Asian region.

Materials and Methods:

We provided an overview of the prevalence and incidence of CVD and its risk factors in adult HIV-positive populations, and of the strategies currently in place for CVD management in the Asian region.

Results:

Studies from the Asian region showed that CVD and CVD risk factors, such as dyslipidaemia, elevated blood glucose, obesity and smoking, are highly prevalent in HIV-positive populations. A number of studies suggested that HIV infection and antiretroviral therapy may contribute to increased CVD risk. National HIV treatment guidelines provide some directions regarding CVD risk prevention and management in the HIV-infected population, however, they are limited in number and scope.

Conclusion:

Development and consolidation of guidelines for integrated CVD and HIV care are essential to control the burden of CVD in HIV-positive populations. To inform guidelines, policies and practice in the Asian region, research should focus on exploring appropriate CVD risk screening strategies and estimating current and future CVD mortality and morbidity rates.

Metabolic Complications among Korean Patients with HIV Infection: The Korea HIV/AIDS Cohort Study

Currently, metabolic complications are the most common problem among human immunodeficiency virus (HIV)-infected patients, with a high incidence. However, there have been very few studies regarding metabolic abnormalities published in Asia, especially in Korea. This cross-sectional study was performed to investigate the prevalence of and risk factors for metabolic abnormalities in 1,096 HIV-infected patients of the Korea HIV/AIDS cohort study enrolled from 19 hospitals between 2006 and 2013. Data at entry to cohort were analyzed. As a result, the median age of the 1,096 enrolled subjects was 46 years, and most patients were men (92.8%). The metabolic profiles of the patients were as follows: median weight was 63.8 kg, median body mass index (BMI) was 22.2 kg/m², and 16.4% of the patients had a BMI over 25 kg/m². A total of 5.5% of the patients had abdominal obesity (waist/hip ratio ≥ 1 in men, ≥ 0.85 in women). Increased levels of fasting glucose, total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides were present in 10.4%, 6.0%, 5.5%, and 32.1% of the patients. Decreased high-density lipoprotein (HDL) cholesterol levels were observed in 44.2% of the patients. High systolic blood pressure was present in 14.3% of the patients. In multivariate analysis, high BMI and the use of protease inhibitors (PIs) were risk factors for dyslipidemia in HIV-infected patients. In conclusion, proper diagnosis and management should be offered for the prevalent metabolic complications of Korean HIV-infected patients. Further studies on risk factors for metabolic complications are needed.

[Obesity, high blood pressure, hypercholesterolaemia, and untreated diabetes in HIV-infected and HIV-uninfected Adults in Mbuji-Mayi (Democratic republic of congo)]

Little is known about the major cardiovascular risk factors in HIV-infected as compared to the HIV-uninfected patients in the Democratic Republic of Congo (DR Congo). We determined the prevalence of hypertension, obesity (BMI ≥ 30 kg/m²), total cholesterol > 200 mg/dl, HDLcholesterol &≤ 40 mg/dl, and glycemia > 126 mg/dl. We also calculated the average and/or median of total cholesterol, HDL-cholesterol, and glycemia among HIV-infected and HIV-uninfected patients.We conducted a cross-sectional study that enrolled 592 HIV-uninfected and 445 HIV-infected patients of whom 425 (95.5%) were on first-line antiretroviral therapy based on stavudine-lamivudine-nevirapine. Clinical and laboratory data of the patients were collected. The results were analyzed by chi-square, t-student, and Wilcoxon rank sum tests. 11.5% of HIV-infected patients had an average blood pressure suggesting hypertension versus 10.6% of HIV-uninfected (P = 0.751). But in absolute value, HIVinfected patients had a median of diastolic blood pressure of 90 mmHg versus 85 mmHg of HIV-uninfected (P < 0.001). 4.04% of HIV-infected patients had a BMI suggesting obesity versus 6.08% of HIV-uninfected patients (P = 0.187). For fasting glucose: 2.50% of HIV-infected patients versus 4.20% of HIV-uninfected patients had a serum fasting glucose suggesting diabetes (P<0.176). 11.9% of HIV-infected patients had a total cholesterol greater than 200 mg/dl versus 7.4% of HIVuninfected patients (P=0.019). For HDL-cholesterol: 36.40% of HIV-infected patients had a serum fasting ≤ 40 mg/dl versus 15.70% of HIV-uninfected patients (P < 0.001). HIV-infected patients had a median fasting total cholesterol higher (140 mg/ dl) thanHIV-uninfected patients (133mg/dl) [P=0.015].HIVuninfected patients had a median fasting HDL-cholesterol higher (58.5 mg/dl) than HIV-infected patients (49 mg/dl) [P < 0.001]. HIV-infected women were more likely to have a higher mean of total cholesterol: 147.70 #x00B1; 52.09 mg/dl versus 135.72 &#x00B1; 48.23 mg/dl for the HIV-infected men (P = 0.014) and of HDL-cholesterol: 55.80 ± 30.77 mg/dl versus 48.24 ± 28.57mg/dl for the HIV-infected men (P = 0.008). In this study population, prevalence of hypertension was elevated in HIVinfected versus HIV-uninfected patients. Being HIV positive on first-line antiretroviral therapy based on stavudine-lamivudine-nevirapine was associated with high prevalence of total cholesterol > 200 mg/dl and HDL-cholesterol ≤ 40 mg/dl. Proactive screening and prompt management of dyslipidemia and hypertension in this population should be a priority.

A Meta-Analysis of the Metabolic Syndrome Prevalence in the Global HIV-Infected Population

BACKGROUND

Cardio-metabolic risk factors are of increasing concern in HIV-infected individuals, particularly with the advent of antiretroviral therapy (ART) and the subsequent rise in longevity. However, the prevalence of cardio-metabolic abnormalities in this population and the differential contribution, if any, of HIV specific factors to their distribution, are poorly understood. Therefore, we conducted a systematic review and meta-analysis to estimate the global prevalence of metabolic syndrome (MS) in HIV-infected populations, its variation by the different diagnostic criteria, severity of HIV infection, ART used and other major predictive characteristics.

METHODS

We performed a comprehensive search on major databases for original research articles published between 1998 and 2015. The pooled overall prevalence as well as by specific groups and subgroups were computed using random effects models.

RESULTS

A total of 65 studies across five continents comprising 55094 HIV-infected participants aged 17-73 years (median age 41 years) were included in the final meta-analysis. The overall prevalence of MS according to the following criteria were: ATPIII-2001:16.7% (95%CI: 14.6-18.8), IDF-2005: 18% (95%CI: 14.0-22.4), ATPIII-2004-2005: 24.6% (95%CI: 20.6-28.8), Modified ATPIII-2005: 27.9% (95%CI: 6.7-56.5), JIS-2009: 29.6% (95%CI: 22.9-36.8), and EGIR: 31.3% (95%CI: 26.8-36.0). By some MS criteria, the prevalence was significantly higher in women than in men (IDF-2005: 23.2% vs. 13.4, p = 0.030), in ART compared to non-ART users (ATPIII-2001: 18.4% vs. 11.8%, p = 0.001), and varied significantly by participant age, duration of HIV diagnosis, severity of infection, non-nucleoside reverse transcriptase inhibitors (NNRTIs) use and date of study publication. Across criteria, there were significant differences in MS prevalence by sub-groups such as in men, the Americas, older publications, regional studies, younger adults, smokers, ART-naïve participants, NNRTIs users, participants with shorter duration of diagnosed infection and across the spectrum of HIV severity. Substantial heterogeneities across and within criteria were not fully explained by major study characteristics, while evidence of publication bias was marginal.

CONCLUSIONS

The similar range of MS prevalence in the HIV-infected and general populations highlights the common drivers of this condition. Thus, cardio-metabolic assessments need to be routinely included in the holistic management of the HIV-infected individual. Management strategies recommended for MS in the general population will likely provide similar benefits in the HIV-infected.

Metabolic abnormalities in human immunodeficiency virus patients with protease inhibitor-based therapy

CONTEXT

Several studies have reported metabolic abnormalities in patients taking protease inhibitor (PI) based therapy from several parts of the world. But there is no prospective study in India after switching from PI sparing regimen to PI based regimen.

AIMS

To assess whether North-East Indian Human Immunodeficiency Virus (HIV) patients also develop similar metabolic abnormalities to PI.

SETTINGS AND DESIGN

This prospective study was conducted in Anti-retroviral therapy (ART) Centre of Excellence, at a tertiary care Medical Institute.

MATERIALS AND METHODS

Fifty-five patients taking PI based ART were taken for the study. These patients were started on Ritonavir based therapy, after treatment with first line drugs had failed according to National AIDS Control Organization (NACO) guidelines 2008. Glucose and lipid profiles were evaluated. American Diabetes Association (ADA) and NCEP ATP III criteria were used to categorize glucose and lipid abnormalities. International Diabetes Federation (IDF) 2006 cut-off was used for waist circumference and blood pressure.

STATISTICAL ANALYSIS USED

Paired t-test was done whenever applicable.

RESULTS

There was a significant increase in waist circumference after 6 months of 2(nd) line ART from 78.0 cm to 80.2 cm (P value < 0.001). There was significant increase in both systolic and diastolic blood pressure after 6 months. In 29.8% of patients blood pressure rose to hypertensive level after 6 months. Total cholesterol, triglyceride and low density lipoprotein cholesterol also rose significantly after 6 months but not high density lipoprotein cholesterol.

CONCLUSIONS

Our study showed that North-Eastern Indian patients also develop metabolic abnormalities to protease inhibitors similar to people of other races.

HIV/AIDS and lipodystrophy: implications for clinical management in resource-limited settings

Introduction

Lipodystrophy is a term used to describe a metabolic complication of fat loss, fat gain, or a combination of fat loss and gain, which is associated with some antiretroviral (ARV) therapies given to HIV-infected individuals. There is limited research on lipodystrophy in low- and middle-income countries, despite accounting for more than 95% of the burden of HIV/AIDS. The objective of this review was to evaluate the prevalence, pathogenesis and prognosis of HIV-related lipoatrophy, lipohypertrophy and mixed syndrome, to inform clinical management in resource-limited settings.

Methods

We conducted a structured literature search using MEDLINE electronic databases. Relevant MeSH terms were used to identify published human studies on HIV and lipoatrophy, lipohypertrophy, or mixed syndrome in low-, low-middle- and upper-middle-income countries through 31 March 2014. The search resulted in 5296 articles; after 1599 studies were excluded (958 reviews, 641 non-human), 3697 studies were extracted for further review. After excluding studies conducted in high-income settings (n=2808), and studies that did not meet inclusion criteria (n=799), 90 studies were included in this review.

Results and Discussion

Of the 90 studies included in this review, only six were from low-income countries and eight were from lower middle-income economies. These studies focused on lipodystrophy prevalence, risk factors and side effects of antiretroviral therapy (ART). In most studies, lipodystrophy developed after the first six months of therapy, particularly with the use of stavudine. Lipodystrophy is associated with increased risk of cardiometabolic complications. This is disconcerting and anticipated to increase, given the rapid scale-up of ART worldwide, the increasing number and lifespan of HIV-infected patients on long-term therapy, and the emergence of obesity and non-communicable diseases in settings with extensive HIV burden.

Conclusions

Lipodystrophy is common in resource-limited settings, and has considerable implications for risk of metabolic diseases, quality of life and adherence. Comprehensive evidence-based interventions are urgently needed to reduce the burden of HIV and lipodystrophy, and inform clinical management in resource-limited settings.

Association between nutritional status and the immune response in HIV + patients under HAART: protocol for a systematic review

BACKGROUND

Over 850 million people worldwide and 200 million adults in Sub-Saharan Africa suffer from malnutrition. Countries most affected by HIV are also stricken by elevated rates of food insecurity and malnutrition. HIV infection and insufficient nutritional intake are part of a vicious cycle that contributes to immunodeficiency and negative health outcomes. However, the effect of the overlap between HIV infection and undernutrition on the immune response following antiretroviral initiation remains unclear. A possible explanation could be the lack of consensus concerning the definition and assessment of nutritional status. Our objectives are to investigate the existence of an association between undernutrition and immune response at antiretroviral treatment initiation and the following year in low- and middle-income countries where malnutrition is most prevalent.

METHODS/DESIGN

Our systematic review will identify studies originating from low- and middle-income countries (LMICs) published from 1996 onwards, through searches in MEDLINE (PubMed interface), EMBASE (OVID interface), Cochrane Central (OVID interface) and grey literature. No language restrictions will be applied. We will seek out studies of any design investigating the association between the nutritional status (for example, undernourished versus well nourished) and the immune response, either in terms of CD4 count or immune failure, in seropositive patients initiating antiretroviral therapy or in their first year of treatment. Two reviewers will independently screen articles, extract data and assess scientific quality using standardized forms and published quality assessment tools tailored for each study design. Where feasible, pooled measures of association will be obtained through meta-analyses. Results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. This protocol has been registered in the PROSPERO database (registration number: CRD42014005961).

CONCLUSION

Undernutrition and weight loss are prevalent amongst highly active antiretroviral therapy (HAART)-treated patients in LMICs and contribute to excess early mortality. A possible intermediate pathway could be poor immune reconstitution secondary to deficient nutritional status. In the face of limited access to second line treatments, raising HIV resistance and cut backs to HIV programs, it is crucial to identify the factors associated with suboptimal response and therapeutic failure in order to better customize the care strategies employed in LMICs.

HIV lipodystrophy in participants randomised to lopinavir/ritonavir (LPV/r) +2-3 nucleoside/nucleotide reverse transcriptase inhibitors (N(t)RTI) or LPV/r + raltegravir as second-line antiretroviral therapy

Objective

To compare changes over 48 weeks in body fat, lipids, Metabolic Syndrome and cardiovascular disease risk between patients randomised 1∶1 to lopinavir/ritonavir (r/LPV) plus raltegravir (RAL) compared to r/LPV plus 2–3 nucleoside/nucleotide reverse transcriptase inhibitors (N(t)RTIs) as second-line therapy.

Methods

Participants were HIV-1 positive (>16 years) failing first-line treatment (2 consecutive HIV RNA >500 copies/mL) of NNRTI +2N(t)RTI. Whole body dual energy x-ray absorptiometry was performed at baseline and week 48. Data were obtained to calculate the Metabolic Syndrome and Framingham cardiovascular disease (CVD) risk score. Linear regression was used to compare mean differences between arms. Logistic regression compared incidence of metabolic syndrome. Associations between percent limb fat changes at 48 weeks with baseline variables were assessed by backward stepwise multivariate linear regression. Analyses were adjusted for gender, body mass index and smoking status.

Results

210 participants were randomised. The mean (95% CI) increase in limb fat over 48 weeks was 15.7% (5.3, 25.9) or 0.9 kg (0.2, 1.5) in the r/LPV+N(t)RTI arm and 21.1% (11.1, 31,1) or 1.3 kg (0.7, 1.9) in the r/LPV+RAL arm, with no significant difference between treatment arms (−5.4% [−0.4 kg], p>0.1). Increases in total body fat mass (kg) and trunk fat mass (kg) were also similar between groups. Total:HDL cholesterol ratio was significantly higher in the RAL arm (mean difference −0.4 (1.4); p = 0.03), there were no other differences in lipid parameters between treatment arms. There were no statistically significant differences in CVD risk or incidence of Metabolic Syndrome between the two treatment arms. The baseline predictors of increased limb fat were high viral load, high insulin and participant's not taking lipid lowering treatment.

Conclusion

In patients switching to second line therapy, r/LPV combined with RAL demonstrated similar improvements in limb fat as an N(t)RTI + r/LPV regimen, but a worse total:HDL cholesterol ratio over 48 weeks.

Trial Registration

This clinical trial is registered on Clinicaltrials.gov, registry number NCT00931463.

Weight and lean body mass change with antiretroviral initiation and impact on bone mineral density

OBJECTIVE

To compare the effect that initiating different antiretroviral therapy (ART) regimens has on weight, BMI, and lean body mass (LBM) and explore how changes in body composition are associated with bone mineral density (BMD).

METHODS

A5224s was a sub-study of A5202, a prospective trial of 1857 ART-naive participants randomized to blinded abacavir-lamivudine (ABC/3TC) or tenofovir DF-emtricitabine (TDF/FTC) with open-label efavirenz (EFV) or atazanavir-ritonavir (ATV/r). All participants underwent dual-energy absorptiometry (DXA) and abdominal computed tomography for body composition. Analyses used two-sample t-tests and linear regression.

RESULTS

A5224s included 269 participants: 85% men, 47% white non-Hispanic, median age 38 years, HIV-1 RNA 4.6 log10 copies/ml, and CD4 cell count 233 cells/μl. Overall, significant gains occurred in weight, BMI, and LBM at 96 weeks post-randomization (all P<0.001). Assignment to ATV/r (vs. EFV) resulted in significantly greater weight (mean difference 3.35 kg) and BMI gain (0.88 kg/m; both P=0.02), but not LBM (0.67 kg; P=0.15), whereas ABC/3TC and TDF/FTC were not significantly different (P≥0.10). In multivariable analysis, only lower baseline CD4 cell count and higher HIV-1 RNA were associated with greater increase in weight, BMI, or LBM. In multivariable analyses, increased LBM was associated with an increased hip BMD.

CONCLUSION

ABC/3TC vs. TDF/FTC did not differ in change in weight, BMI, or LBM; ATV/r vs. EFV resulted in greater weight and BMI gain but not LBM. A positive association between increased LBM and increased hip BMD should be further investigated through prospective interventional studies to verify the impact of increased LBM on hip BMD.