Cardiovascular disease and toxicities related to HIV infection and its therapies

ROS Chronicles in HIV Infection: Genesis of Oxidative Stress, Associated Pathologies, and Therapeutic Strategies

Reactive oxygen species (ROS) are widely regarded as signaling molecules and play essential roles in various cellular processes, but when present in excess, they can lead to oxidative stress (OS). Growing evidence suggests that the OS plays a critical role in the pathogenesis of HIV infection and is associated with several comorbidities in HIV-infected individuals. ROS, generated both naturally during mitochondrial oxidative metabolism and as a response to various cellular processes, can trigger host antiviral responses but can also promote viral replication. While the multifaceted roles of ROS in HIV pathophysiology clearly need more investigation, this review paper unravels the mechanisms of OS generation in the context of HIV infections, offering insights into HIV viral protein-mediated and antiretroviral therapy-generated OS. Though the viral protein Tat is significantly attributed to the endogenous cellular increase in ROS post HIV infection, this paper sums up the contribution of other viral proteins in HIV-mediated elicitation of ROS. Given the investigations recognizing the significant role of ROS in the onset and progression of diverse pathologies, the paper also explores the critical function of ROS in the mediation of an of array of pathologies associated with HIV infection and retroviral therapy. HIV patients are observed with disruption to the antioxidant defense system, the antioxidant therapy is gaining focus as a potential therapeutic intervention and is well discussed. While ROS play a significant role in the HIV scenario, further exploratory studies are imperative to identifying alternative therapeutic strategies that could mitigate the toxicities and pathologies associated with ART-induced OS.

Blood pressure responses after resistance exercise session in women living with human immunodeficiency virus/acquired immunodeficiency syndrome

The aim of this study was to verify blood pressure (BP) responses after a single resistance exercise session in women with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Twelve patients underwent a resisted exercise session. BP, heart rate, and rate pressure product were evaluated before and during 120 min after the session. Mean cardiovascular values before and after the session were similar (P>0.05). Analysis of the individual data revealed that for 120 min after exercise, 5 and 4 patients presented a reduction in systolic and diastolic BP of ≥4 mmHg, respectively. The clinical characteristics of the patients appear to influence BP responses after exercise. Individual data showed that some of the HIV+ women demonstrated a clinically significant decrease in BP. Although a single resistance exercise session does not decrease BP in women with HIV/AIDS, individual data present heterogeneity and individual characteristics seem to influence BP reduction after a single session of resistance exercises.

Treinamento físico no risco de doença isquêmica cardíaca em sujeitos HIV/AIDS em uso de TARV

INTRODUÇÃO: A terapia antirretroviral combinada (TARV) foi introduzida no Brasil em 1996, como parte da política nacional de acesso gratuito aos serviços de saúde e medicamentos. Infelizmente, o seu uso contínuo tem sido associado com mudanças na distribuição da gordura corporal e com alterações metabólicas que podem aumentar a morbidade e mortalidade nesta população. O treinamento físico tem sido estudado como uma estratégia eficaz de intervenção não farmacológica para melhorar os parâmetros de aptidão física relacionados à saúde e para minimizar os efeitos indesejáveis da infecção pelo HIV e/ou o uso prolongado da TARV, no entanto, há poucos estudos sobre o treinamento físico, síndrome lipodistrófica e cardiologia.OBJETIVO: Avaliar o risco de doença isquêmica cardíaca em sujeitos HIV/AIDS em uso de TARV praticantes de treinamento concorrente com séries simples.MÉTODOS: Quatorze sujeitos foram avaliados através da circunferência abdominal, pressão arterial sistólica (PAS) e diastólica (PAD), colesterol total (CT), HDL, LDL, triglicerídeos (TG) e glicemia. Para a estimativa do risco coronariano em 10 anos utilizou-se o Escore de Framingham.RESULTADOS: A maioria dos sujeitos situou-se dentro dos valores de referência para as variáveis analisadas, exceto para os valores de LDL e TG. Treze sujeitos (92,7%) ficaram abaixo dos 10% de risco coronariano em 10 anos, e apenas um (7,3%) estava em risco moderado. Houve correlação significativa entre o tempo de treinamento e a PAS.CONCLUSÃO: Sugere-se a realização de ensaios clínicos randomizados para avaliar os mesmos desfechos deste estudo.

Cardiac effects in perinatally HIV-infected and HIV-exposed but uninfected children and adolescents: a view from the United States of America

Introduction

Human immunodeficiency virus (HIV) infection is a primary cause of acquired heart disease, particularly of accelerated atherosclerosis, symptomatic heart failure, and pulmonary arterial hypertension. Cardiac complications often occur in late-stage HIV infections as prolonged viral infection is becoming more relevant as longevity improves. Thus, multi-agent HIV therapies that help sustain life may also increase the risk of cardiovascular events and accelerated atherosclerosis.

Discussion

Before highly active antiretroviral therapy (HAART), the two-to-five-year incidence of symptomatic heart failure ranged from 4 to 28% in HIV patients. Patients both before and after HAART also frequently have asymptomatic abnormalities in cardiovascular structure. Echocardiographic measurements indicate left ventricular (LV) systolic dysfunction in 18%, LV hypertrophy in 6.5%, and left atrial dilation in 40% of patients followed on HAART therapy. Diastolic dysfunction is also common in long-term survivors of HIV infection. Accelerated atherosclerosis has been found in HIV-infected young adults and children without traditional coronary risk factors. Infective endocarditis, although rare in children, has high mortality in late-stage AIDS patients with poor nutritional status and severely compromised immune systems. Although lymphomas have been found in HIV-infected children, the incidence is low and cardiac malignancy is rare. Rates of congenital cardiovascular malformations range from 5.6 to 8.9% in cohorts of HIV-uninfected and HIV-infected children with HIV-infected mothers. In non-HIV-infected infants born to HIV-infected mothers, foetal exposure to ART is associated with reduced LV dimension, LV mass, and septal wall thickness and with higher LV fractional shortening and contractility during the first two years of life.

Conclusions

Routine, systematic, and comprehensive cardiac evaluation, including a thorough history and directed laboratory assays, is essential for the care of HIV-infected adults and children as cardiovascular illness has become a part of care for long-term survivors of HIV infection. The history should include traditional risk factors for atherosclerosis, prior opportunistic infections, environmental exposures, and therapeutic and illicit drug use. Laboratory tests should include a lipid profile, fasting glucose, and HIV viral load. Asymptomatic cardiac disease related to HIV can be fatal, and secondary effects of HIV infection often disguise cardiac symptoms, so systematic echocardiographic monitoring is warranted.

Patterns, predictors, and consequences of initial regimen type among HIV-infected women receiving highly active antiretroviral therapy

BACKGROUND

It is important to elucidate differences among initial highly active antiretroviral therapy (HAART) regimen types in comparative studies of therapy effectiveness. We aimed to identify predictors of initiation with different HAART regimen types and the effect of initial regimen type on switching and immunologic response to therapy--controlling for those predictors--among human immunodeficiency virus (HIV)-infected women in the United States.

METHODS

Participants in the Women's Interagency HIV Study underwent semiannual interview, venipuncture, and clinical examination. Those beginning with protease inhibitor-based, nonnucleoside reverse-transcriptase inhibitor (NNRTI)-based, or triple-nucleoside reverse-transcriptase inhibitor (NRTI)-based HAART during April 1996-March 2005 were eligible for analysis. Predictors of initial regimen type were assessed with polytomous logistic regression. Correlates of switching were assessed with discrete-time proportional hazards models, and immunologic response to therapy was assessed with linear regression.

RESULTS

Among 1555 HAART initiators, CD4(+) lymphocyte count and HIV load were significant predictors of initial regimen type during 1996-2002; only sociodemographic predictors were significant during 2002-2005. Initial regimen type was not a significant predictor of subsequent regimen switching. Compared with those whose initial treatment was protease inhibitor-based HAART, those who began with triple-NRTI-based regimens had significantly lower CD4(+) cell counts at 1 year (P=.006) and 2 years (P=.004) after initiation; NNRTI initiators had lower CD4(+) cell counts after 2 years (P=.05).

CONCLUSIONS

We demonstrate that predictors of initial regimen type among women in the United States have been changing over time. Protease inhibitor initiators had significantly higher CD4(+) cell counts than did NNRTI or triple-NRTI initiators up to 2 years after HAART initiation. Adjustment for biological predictors of initial regimen is important to avoid confounding in the study of treatment effectiveness.

Impact of HIV and highly active antiretroviral therapy on leukocyte adhesion molecules, arterial inflammation, dyslipidemia, and atherosclerosis

Highly active antiretroviral therapy (HAART) has greatly extended the lives of people infected with the human immunodeficiency virus (HIV). This reduced risk of early death from opportunistic infections or other sequelae of HIV infection, however, means that other possible causes of death emerge. Myocardial infarction has become a matter of particular concern. Two of the main sources of cardiovascular disease in this population are believed to be vascular inflammation and dyslipidemia. We review the evidence for this hypothesis and discuss the relationship of HIV to vascular inflammation. Current treatment guidelines do not recommend the immediate initiation of HAART unless warranted, potentially allowing long-term, unchecked viral impact on the development of atherosclerosis. Finally, we consider the protease inhibitors traditionally included in HAART regimens and their relationship to the development of dyslipidemia, as well as other classes of antiretrovirals, such as the non-nucleoside reverse transcriptase inhibitors, which might be a better choice for patients with cardiovascular risks. Other strategies, such as pharmacologic, nutritional, and physical activity interventions are discussed. The patients who might benefit most are those in whom the precursors of vascular plaques, such as fatty streak, smooth muscle cell, macrophage, and T-lymphocyte aggregation not yet identified by echocardiographic and biopsy findings have already developed as a result of unchecked viral inflammation and replication.