Prediction of coronary heart disease risk in HIV-infected patients with fat redistribution

Sagittal Abdominal Diameter as the Best Predictor of Metabolic Syndrome in HIV-Infected Men on Antiretroviral Therapy

BACKGROUND

The interaction of human immunodeficiency virus (HIV), host and antiretroviral therapy (ART) causes a range of metabolic disorders that can be characterized as a metabolic syndrome (MetS) that increases the cardiovascular risk. MetS involves central obesity, which can be detected using different anthropometric parameters.

OBJECTIVE

To assess the abilities of different anthropometric parameters in the prediction of MetS in HIV-infected men on ART.

METHOD

The study involved 92 male participants (mean age 44.46±10.38 years), divided into two groups: with and without MetS. All subjects underwent biochemical evaluation (triglycerides, HDL-cholesterol, fasting glucose), blood pressure measurement and anthropometric assessment: body mass, body height, body mass index (BMI), body fat mass, body circumferences (chest, upper arm, forearm, waist, hip, proximal and middle thigh and calf), sagittal abdominal diameter (SAD), skinfold thicknesses (subscapular, anterior and posterior upper arm, anterior and lateral forearm, abdominal, supraspinal, thigh and calf), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), waist-to-thigh ratio (WTR), sagittal abdominal diameter-to-body height ratio (SADH), body adiposity index (BAI) and conicity index. MetS was specified according to IDF criteria.

RESULTS

Subjects with MetS had statistically significant higher values of all anthropometric parameters except middle thigh circumference, calf skinfold and body height. According to ROC analysis and Binary Logistic Regression, SAD has been shown as the best predictor of MetS with a predictive value of 21.40 cm (AUC:0.91), followed by WHR with a predictive value of 0.93.

CONCLUSION

Sagittal abdominal diameter is the strongest anthropometric indicator of MetS in HIV-infected patients on ART.

Vitamin C Urinary Loss and Deficiency in Human Immunodeficiency Virus (HIV): Cross-sectional Study of Vitamin C Renal Leak in Women With HIV

BACKGROUND

Reduced plasma vitamin C (vitC) concentrations in human immunodeficiency virus (HIV) may result from abnormal urinary excretion: a renal leak. VitC renal leak indicates underlying nutritional dysregulation independent of diet. We hypothesized that increased renal leak prevalence in HIV would be associated with deficient vitC concentrations.

METHODS

We conducted an outpatient cross-sectional study of 96 women (40 HIV [PWH] and 56 without HIV [PWOH]) at the National Institutes of Health and Georgetown University. Renal leak was defined as abnormal urinary vitC excretion at fasting plasma concentrations <43.2µM, 2 SDs below vitC renal threshold in healthy women. To determine the primary outcome of renal leak prevalence, matched urine and plasma samples were collected the morning after overnight fast. Secondary outcomes assessed group differences in mean plasma vitC concentrations and prevalence of vitC deficiency. Exploratory outcomes assessed clinical parameters associated with renal leak. VitC was measured by high-performance liquid chromatography with coulometric electrochemical detection.

RESULTS

PWH had significantly higher renal leak prevalence (73%vs14%; OR (odds ratio):16; P<.001), lower mean plasma vitC concentrations (14µMvs50µM; P<.001), and higher prevalence of vitC deficiency (43%vs7%; OR:10; P<.001) compared with PWOH, unchanged by adjustments for confounding factors. Significant predictors of renal leak included antiretroviral therapy (ART), Black race, older age, and metabolic comorbidities but not viral load or CD4 count. When compared with other chronic disease cohorts, PWH had the highest prevalence of renal leak and vitC deficiency (P<.001).

CONCLUSIONS

High prevalence of vitC renal leak in HIV was associated with vitC deficiency, ART use, and race/ethnicity differences.

Adipocytokine dysregulation, abnormal glucose metabolism, and lipodystrophy in HIV-infected adolescents receiving protease inhibitors

BACKGROUND

Lipodystrophy is common in HIV-infected patients receiving protease inhibitors (PIs), stavudine, and zidovudine. Adipocytokines may be altered in lipodystrophy. We evaluated risk factors, adipocytokine levels, insulin resistance, and lipid profiles in HIV-infected adolescents with different lipodystrophy types.

METHODS

A cross-sectional study was conducted in 80 perinatally HIV-infected adolescents receiving PI-based highly active antiretroviral therapy for ≥ 6 months. Patients underwent oral glucose tolerance tests and measurements of high-molecular-weight (HMW) adiponectin, leptin, resistin, insulin, and lipids. They were classified into 3 groups based on the clinical findings: no lipodystrophy, isolated lipoatrophy, and any lipohypertrophy (isolated lipohypertrophy or combined type).

RESULTS

Of the 80 patients (median age, 16.7 years), 18 (22.5%) had isolated lipoatrophy, while 8 (10%) had any lipohypertrophy (four with isolated lipohypertrophy, and four with the combined type). In a multivariate analysis, longer exposure to stavudine (OR: 1.03; 95% CI, 1.01-1.06; p = 0.005) and indinavir (OR: 1.03; 95% CI, 1.01-1.06; p = 0.012) were associated with lipoatrophy, while longer exposure to didanosine (OR: 1.04; 95% CI, 1.01-1.08; p = 0.017) and indinavir (OR: 1.10; 95% CI, 1.00-1.21; p = 0.045) were associated with any lipohypertrophy. Leptin levels were highest in the any-lipohypertrophy group and lowest in the isolated-lipoatrophy group (p = 0.013). HMW adiponectin levels were significantly lowest in the any-lipohypertrophy group and highest in the no-lipodystrophy group (p = 0.001). There were no significant differences in the levels of resistin among the three groups (p = 0.234). The prevalence of insulin resistance (p = 0.002) and prediabetes/diabetes (p < 0.001) were significantly highest in the any-lipohypertrophy group. Patients with lipoatrophy and those without lipodystrophy had comparable degrees of insulin resistance (p = 0.292). In multiple linear regression analysis, adjusted for age, sex, and waist-height ratio, HMW adiponectin levels were associated with Matsuda index (β = 0.5; p = 0.003) and quantitative insulin sensitivity check index (QUICKI) (β = 40.1; p = 0.010) and almost significantly associated with homeostatic model assessment of insulin resistance (HOMA-IR) (p = 0.054). Leptin and resistin levels were not associated with HOMA-IR, Matsuda index, or QUICKI (all p > 0.05).

CONCLUSIONS

Abnormal glucose metabolism and dysregulation of adipocytokines were common in the HIV-infected adolescents with lipohypertrophy and the combined type. Preventive screening for cardiovascular diseases caused by metabolic alterations should be routinely performed.

[Cardiovascular risk calculators for people living with human immunodeficiency virus]

The increasing access and efficacy of antiretroviral therapy has allowed people living with human immunodeficiency virus to achieve a life expectancy similar to that of the general population. However, this goal may be affected by the increased risk of cardiovascular disease in this group. This risk is multifactorial, involving the high prevalence of traditional risk factors, the development of a pro-inflammatory state related to chronic infection, and the use of antiretroviral drugs with an adverse metabolic profile. In daily practice, in order to estimate this risk and guide medical decision-making, different calculators are available. These are based on data from population cohorts, many of them from human immunodeficiency virusnegative subjects. The main aim of this review is to describe the epidemiology of cardiovascular disease in people living with human immunodeficiency virus, the available risk calculators and their use.

Excess Risk for Atherosclerotic Cardiovascular Outcomes Among US Adults With HIV in the Current Era

Background In the 2000s, adults with HIV had a higher risk for atherosclerotic cardiovascular disease (ASCVD) compared with those without HIV. There is uncertainty if this excess risk still exists in the United States given changes in antiretroviral therapies and increased statin use. Methods and Results We compared the risk for ASCVD events between US adults aged ≥19 years with and without HIV who had commercial or supplemental Medicare health insurance between January 1, 2011, and December 31, 2016. Beneficiaries with HIV (n=82 426) were frequency matched 1:4 on age, sex, and calendar year to those without HIV (n=329 704). Beneficiaries with and without HIV were followed up through December 31, 2016, for ASCVD events, including myocardial infarction, stroke, and lower extremity artery disease hospitalizations. Most beneficiaries were aged <55 years (79%) and men (84%). Over a median follow-up of 1.6 years (maximum, 6 years), there were 3287 ASCVD events, 2190 myocardial infarctions, 891 strokes, and 322 lower extremity artery disease events. The rate per 1000 person-years among beneficiaries with and without HIV was 5.53 and 3.49 for ASCVD, respectively, 3.58 and 2.34 for myocardial infarction, respectively, 1.49 and 0.94 for stroke, respectively, and 0.65 and 0.31 for lower extremity artery disease hospitalizations, respectively. The multivariable-adjusted hazard ratio (95% CI) for ASCVD, myocardial infarction, stroke, and lower extremity artery disease hospitalizations comparing beneficiaries with versus without HIV was 1.29 (1.18-1.40), 1.26 (1.13-1.39), 1.30 (1.11-1.52), and 1.46 (1.11-1.92), respectively. Conclusions Adults with HIV in the United States continue to have a higher ASCVD risk compared with their counterparts without HIV.

Comparison of visceral fat measurement by dual-energy X-ray absorptiometry to computed tomography in HIV and non-HIV

Background/Objectives

Individuals with HIV are susceptible to visceral fat accumulation, which confers an increased risk of cardiometabolic disease. Advanced software to ascertain visceral fat content from dual-energy X-ray absorptiometry (DXA) has not been validated among this population. We sought to compare DXA with computed tomography (CT) in the measurement of visceral fat cross-sectional area (VAT) in HIV and non-HIV using Bland–Altman analyses.

Subjects/Methods

Data were combined from five previously conducted studies of individuals with HIV (n = 313) and controls without HIV (n = 144) in which paired DXA and CT scans were available. In cross-sectional analyses, DXA-VAT was compared with CT-VAT among participants with and without HIV. In longitudinal analyses, changes in VAT over time were compared between DXA and CT among participants with and without HIV receiving no intervention over 12 months and among individuals with HIV receiving tesamorelin—a medication known to reduce VAT—over 6 months.

Results

In HIV, DXA underestimated VAT compared with CT among individuals with increased visceral adiposity. The measurement bias was −9 ± 47 cm² overall, but became progressively larger with greater VAT (P < 0.0001), e.g., −61 ± 58 cm² among those with VAT ≥ 200 cm². Sex-stratified analyses revealed that the relationship between VAT and measurement bias was especially pronounced in men (P < 0.0001). Longitudinally, DXA underestimated changes in VAT, particularly among those at the extremes of VAT gain or loss (P < 0.0001). In contrast to the cross-sectional findings, the tendency for DXA to underestimate longitudinal changes in VAT was evident in both men and women. Analogous findings were seen among controls in cross-sectional and longitudinal analyses.

Conclusions

DXA underestimated VAT relative to CT in men with and without HIV, who had increased visceral adiposity. DXA also underestimated changes in VAT over time in men and women, irrespective of HIV status. DXA-VAT should be used with caution among both HIV and non-HIV-infected populations.

C-Reactive Protein as an Independent Cardiovascular Risk Predictor in HIV+ Patients: A Focused Review of Published Studies

Patients infected with the human immunodeficiency virus (HIV+) are living longer and at heightened risk for developing cardiovascular events (CVEs). Commonly used prediction tools appear to misrepresent their CVE risk to varying degrees and in varying directions. Inclusion of markers of cellular infection, chronic immune activation and/or systemic inflammation into risk models might provide better predictive accuracy. Observational studies assessing the relationship of high-sensitivity C-reactive protein (hs-CRP) to CVE in HIV+ patients have reported inconsistent findings. This review of published studies attempted to determine if the available evidence supports its potential use in new models for stable, treated HIV+ patients. We searched the PubMed database using keywords and combinations of “HIV” AND “cardiovascular risk” AND “CRP”. Papers presenting original analyses, associating hs-CRP concentration as an independent variable to hard cardiovascular outcomes (myocardial infarction and cardiovascular death), or to hard CVE as part of a composite endpoint, were included. Five observational studies met inclusion/exclusion criteria for review. Three papers identified an association between elevated hs-CRP and CVE, while two others failed to find any significant association. All reports were heterogeneous in terms of independent variables, controls, and designs. The larger and more rigorous studies, employing higher rates of confounder controls and more objective endpoints in their composites, showed positive associations. Though not conclusive, the preponderance of the evidence at this time supports CRP as a potentially valuable factor to be studied in prospective cardiovascular risk prediction investigations in HIV+ patients.

Changes in coronary heart disease risk profiles of HIV patients in Zimbabwe over 9 months: a follow-up study

Dyslipidemia, hypertension, inflammation, and coronary heart disease (CHD) are adverse events in human immunodeficiency virus (HIV)-infected patients even if they are receiving antiretroviral therapy (ART). Yet, data on CHD risk induced by HIV or ART in sub-Saharan Africa are limited. The aim of this longitudinal study was to describe changes in CHD risk profiles measured by lipids, inflammatory markers, and Framingham scores among HIV-positive patients previously reported from Harare, Zimbabwe. Patients were grouped into ART-experienced patients (n=147) and ART-naïve patients (n=23) and followed up for 9 months. Generalized least squares random-effects modeling was applied to explain changes in total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein, TC/HDL ratio, myeloperoxidase, highly sensitive C-reactive protein, and Framingham scores over the 9-month period. Independent variables included age, sex, monthly earning, body mass index, systolic blood pressure (SBP), diastolic blood pressure, duration of HIV diagnosis, duration of ART, viral load, and CD4 count. In ART-experienced patients, there was a substantial decrease in TC over time, ART-negative patients showed a significant increase in TC and HDL over time, and the increase in TC was associated with high viral load and low duration of HIV diagnosis, while increase in HDL was associated with young age, low body mass index, and low SBP. Framingham risk scores increased with time in ART-positive patients, and the change was positively correlated with age, sex, high SBP, and low HDL. There was no association between calculated CHD risk (TC/HDL ratio or Framingham score) and changes in levels of inflammatory markers (myeloperoxidase and highly sensitive C-reactive protein) in any of the patient groups. In conclusion, ART-experienced HIV-positive patients show changes in lipid values over time that makes it necessary to include lipid monitoring in order to reduce any risk of long-term CHD.

Cardiovascular Disease Risk Prediction in the HIV Outpatient Study

BACKGROUND

 Cardiovascular disease (CVD) risk prediction tools are often applied to populations beyond those in which they were designed when validated tools for specific subpopulations are unavailable.

METHODS

 Using data from 2283 human immunodeficiency virus (HIV)-infected adults aged ≥18 years, who were active in the HIV Outpatient Study (HOPS), we assessed performance of 3 commonly used CVD prediction models developed for general populations: Framingham general cardiovascular Risk Score (FRS), American College of Cardiology/American Heart Association Pooled Cohort equations (PCEs), and Systematic COronary Risk Evaluation (SCORE) high-risk equation, and 1 model developed in HIV-infected persons: the Data Collection on Adverse Effects of Anti-HIV Drugs (D:A:D) study equation. C-statistics assessed model discrimination and the ratio of expected to observed events (E/O) and Hosmer-Lemeshow χ² P value assessed calibration.

RESULTS

 From January 2002 through September 2013, 195 (8.5%) HOPS participants experienced an incident CVD event in 15 056 person-years. The FRS demonstrated moderate discrimination and was well calibrated (C-statistic: 0.66, E/O: 1.01, P = .89). The PCE and D:A:D risk equations demonstrated good discrimination but were less well calibrated (C-statistics: 0.71 and 0.72 and E/O: 0.88 and 0.80, respectively; P < .001 for both), whereas SCORE performed poorly (C-statistic: 0.59, E/O: 1.72; P = .48).

CONCLUSIONS

 Only the FRS accurately estimated risk of CVD events, while PCE and D:A:D underestimated risk. Although these models could potentially be used to rank US HIV-infected individuals at higher or lower risk for CVD, the models may fail to identify substantial numbers of HIV-infected persons with elevated CVD risk who could potentially benefit from additional medical treatment.

Metabolic Syndrome and Cardiovascular Risk in HIV-Infected Patients with Lipodystrophy

In this cross-sectional study, we evaluate potential predictors of Metabolic Syndrome (MS) in a group of 54 Caucasian chronically HIV-infected patients with lipodystrophy. According to ATP-III criteria, 22 patients were affected by MS and 32 were not. The mean age of the sample was 41.2 ± 8.6 years, and most patients were males (74.1%); the two groups were homogeneous for gender, age, viro-immunologic status and the duration of antiviral therapy. The independent association between MS and several factors including demographic characteristics, type of highly-active antiviral therapy (HAART), viro-immunologic response, common cardiovascular risk factors (including Framingham scores), and selected cytokines (IFN-γ, TNF-α, IL-2, IL-4, IL-6, IL-10 and IL-18), was investigated using stepwise forward logistic regression. At multivariate analysis, the only independent predictors of the metabolic syndrome were triglycerides and IL-18. A10 mg/dL increase in triglycerides corresponds to an adjusted risk ratio for MS of 1.11 (95% IC: 1.04–1.19); and patients in the top tertile of IL-18 (those with IL-18 ≥ 530 pg/L) had more than three times the likelihood of MS, as compared to the bottom and medium fertiles of IL-18 (patients with IL-18 < 530 pg/L). This relationship was not attenuated by the inclusion of any other variable in the multivariate model. However, the association between metabolic syndrome and IL-18 is no longer significant when IL-18 is treated as a continuous variable (trend p = 0.087). Our results on HIV patients with lipodystrophy confirm previous findings on a strong independent association between IL-18 and MS in the general population. Further research is needed to clarify the mechanism of this association and its role in the development of cardiovascular disease in HIV patients.

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.

Adiponectin and interleukin-6, but not adipose tissue, are associated with worse neurocognitive function in HIV-infected men

BACKGROUND

Generalized obesity has been associated with cognitive decline, a process potentially mediated by adipocytokines. The effects of regional adipose tissue (AT) on cognition, however, are not well understood. We explored cross-sectional relationships between regional AT, adipocytokines, inflammatory markers and neuropsychological (NP) test scores among HIV+ and HIV- men enrolled in the Multicenter AIDS Cohort Study.

METHODS

Visceral, subcutaneous abdominal and subcutaneous thigh AT areas were quantified by computed tomography (CT). NP tests (Trail Making Test parts A and B, and Symbol-Digit Modalities) obtained within 2 years of CT screened for psychomotor speed and executive function. Adiponectin, leptin, interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hs-CRP) were measured.

RESULTS

Of 509 HIV+ and 271 HIV- participants, HIV+ men (98% on antiretroviral therapy, 81% HIV-1 RNA<50 copies/ml) had lower median subcutaneous AT and adiponectin levels and higher hs-CRP levels, but visceral AT, body mass index, IL-6 and NP scores did not vary by HIV serostatus. In multivariable analysis, older age, ≤ high school education and African American race, but not AT area or site, were associated with worse NP test scores among all participants. In HIV+ only, higher adiponectin and IL-6 were associated with worse cognitive function independent of AT area. No HIV-specific factors were associated with NP test scores.

CONCLUSIONS

Demographic factors were associated with NP test performance, but regional adiposity was not. In HIV+ only, higher adiponectin and IL-6 were associated with worse NP test scores, supporting a role for chronic inflammation and adipocytokine imbalance in neurocognitive decline in HIV+ persons.

Self-reported body fat change in HIV-infected men is a marker of decline in physical health-related quality of life with aging, independent of co-morbidity

OBJECTIVE

Self-perception of changes in body fat among HIV+ persons is associated with decreased health related quality of life in cross-sectional studies. The longitudinal impact of body fat changes on health related quality of life, while accounting for comorbidity and anatomic location or severity of body fat changes, is unknown.

DESIGN

This was a longitudinal analysis of HIV+ and HIV- Multicenter AIDS Cohort Study (MACS) participants who completed questionnaires assessing self-perceived body fat changes (baseline visit) and a health related quality of life (Short Form-36) at baseline and then ≥5 years later.

METHODS

Relationships between body fat changes and change in Short Form-36 Physical and Mental Component Summary scores were investigated using mixed-model regression.

RESULTS

We studied 270 HIV+ and 247 HIV- men. At baseline, ≥50% of HIV+ men reported body fat changes; physical component but not mental component summary scores were lower among HIV+ men who reported moderate/severe leg or abdominal fat changes (p<0.05). At follow-up, physical component summary scores were significantly lower among men with face, leg, or abdominal fat changes compared to men without perceived fat changes (p<0.05). No significant changes were seen in mental component scores by fat change location or severity. In the final model, body fat changes at any site or severity were significant predictors of a decline in physical component summary score (p<0.05), independent of demographics or comorbidities. Mental component summary score was not associated with body fat changes, but higher mental component summary score was associated with increasing age and time.

CONCLUSIONS

Negative self-perceived body fat changes were associated with decline in physical health related quality of life, independent of comorbidities, and may be a marker of an increased risk for physical function decline with aging.

Prevalence of traditional cardiovascular risk factors and evaluation of cardiovascular risk using three risk equations in nigerians living with human immunodeficiency virus

BACKGROUND

Reports from middle- and high-income countries suggest that the improved health outcome from highly active antiretroviral therapy (HAART) in people living with human immunodeficiency virus (PLWHIV) is being mitigated by increase in deaths from cardiovascular disease (CVD).

AIMS

This study was to determine the prevalence of traditional cardiovascular risk factors (CVRFs) and the 10-year cardiovascular risk using three risk equations in PLWHIV with no overt vascular disease.

MATERIALS AND METHODS

This cross-sectional study involved 265 PLWHIV. We classified the subjects as having low, moderate or high cardiovascular risk using the Framingham, World Health Organization/International Society of Hypertension (WHO/ISH) and Systematic Coronary Risk Evaluation (SCORE) equations.

RESULTS

The mean age of the cohort was 38.7 ± 8.7 years; 179 (67.5%) were females and 214 (80.8%) were on HAART. The prevalent traditional CVRFs in our cohort were low physical activity (66%), low HDL-C (49.1%), hypercholesterolaemia (33.6%), BMI ≥ 25 kg/m(2) (32.8%) and elevated LDL-C (28.3%). The prevalence of smoking was very low (1.9%). The prevalence of moderate to high 10-year coronary risk was 11.7, 12.8, and 12.8% according to the Framingham, WHO/ISH and SCORE risk equations, respectively.

CONCLUSION

Most of our patients had low overall cardiovascular risk according to the three risk equations.

Cardiovascular risk-factor knowledge and risk perception among HIV-infected adults

Cardiovascular disease (CVD) has emerged as a major cause of morbidity and mortality in HIV-infected adults. Research in noninfected populations has suggested that knowledge of CVD risk factors significantly influences perceptions of risk. This cross-sectional study describes CVD risk factor knowledge and risk perception in HIV-infected adults. We recruited 130 HIV-infected adults (mean age = 48 years, 62% male, 56% current smokers, mean years since HIV diagnosis, 14.7). The mean CVD risk factor knowledge score was fairly high. However, controlling for age, CVD risk factor knowledge was not predictive of perceived risk [F(1, 117) = 0.13, p > .05]. Estimated risk and perceived risk were weakly but significantly correlated; r (126) = .24, p = .01. HIV-infected adults are at increased risk for CVD. Despite having adequate risk-factor knowledge, CVD risk perception was inaccurate. Improving risk perception and developing CVD risk reduction interventions for this population are imperative.

Association of hepatitis C with markers of hemostasis in HIV-infected and uninfected women in the women's interagency HIV study (WIHS)

BACKGROUND

Coinfection with HIV and hepatitis C virus (HCV) is common. HIV infection and treatment are associated with hypercoagulability; thrombosis in HCV is underinvestigated. Proposed markers of hemostasis in HIV include higher D-dimer, Factor VIII%, and plasminogen activator inhibitor-1 (PAI-1) antigen and lower total Protein S% (TPS) but have not been examined in HCV. We assessed the independent association of HCV with these 4 measures of hemostasis in a multicenter, prospective study of HIV: the Women's Interagency HIV Study.

METHODS

We randomly selected 450 HCV-infected (anti-HCV+ with detectable plasma HCV RNA) and 450 HCV-uninfected (anti-HCV-) women. HCV was the main exposure of interest in regression models.

RESULTS

Four hundred forty-three HCV+ and 425 HCV- women were included. HCV+ women had higher Factor VIII% (124.4% ± 3.9% vs. 101.8% ± 3.7%, P < 0.001) and lower TPS (75.7% ± 1.1% vs. 84.3% ± 1.1%, <0.001) than HCV- women, independent of HIV infection and viral load; there was little difference in PAI-1 or log10 D-dimer. After adjustment for confounders, these inferences remained. HIV infection was independently associated with higher Factor VIII% and log10 D-dimer and lower TPS.

CONCLUSIONS

HCV was independently associated with higher Factor VIII% and lower TPS consistent with hypercoagulability. Higher Factor VIII% and D-dimer and lower TPS were also strongly associated with HIV infection and levels of HIV viremia, independent of HCV infection. Further investigation is needed to determine if there is increased thrombotic risk from HCV. Studies examining hemostasis markers in HIV infection must also assess the contribution of HCV infection.

Anthropometric differences between HIV-infected individuals prior to antiretroviral treatment and the general population from 1998-2007: the AIDS Clinical Trials Group Longitudinal Linked Randomized Trials (ALLRT) cohort and NHANES

OBJECTIVE

To assess differences in body circumferences and body mass index (BMI, kg/m(2)) between antiretroviral treatment (ART) naïve HIV-infected and HIV-uninfected persons.

METHODS

Waist, arm, and thigh circumferences and BMI were measured within the ALLRT and NHANES cohorts between 1998 and 2007. ALLRT is a prospective, longitudinal study of U.S. participants enrolled in randomized HIV treatment studies conducted by the AIDS Clinical Trials Group (ACTG). NHANES is a representative group of the US population. The cohorts were analyzed in two time periods, to account for trends towards increased adiposity. Anthropometrics were displayed in percentiles by age and sex. Multiple linear regression models examined differences between cohorts.

RESULTS

ALLRT had more males (82% versus 48%, p<0.0001), more black participants (32% versus 23%, p<0.0001), and less Hispanics (21% versus 30%, p<0.0001) than NHANES. Mean BMI was smaller in ALLRT males and females compared to NHANES by 1.6-2.4 kg/m(2) (p<0.0001). Mean waist and arm circumferences in both sexes and time periods were significantly smaller in ALLRT than in NHANES (p<0.0001). Mean thigh circumference in ALLRT was also smaller than NHANES among males (p<0.0001 in both time periods) and females (p = 0.01 in the early time period).

CONCLUSIONS

Differences in anthropometrics existed prior to ART initiation, in this large national cohort of HIV-infected individuals, compared to a representative HIV-uninfected cohort, indicating that HIV and its complications have important effects on body shape. Further longitudinal examination of anthropometrics in this HIV-infected cohort may provide additional insight into disease risk.

TRIAL REGISTRATION

NCT00001137 at www.clinicaltrials.gov.

A pilot study of telmisartan for visceral adiposity in HIV infection: the metabolic abnormalities, telmisartan, and HIV infection (MATH) trial

Background

Visceral adiposity in the setting of HIV infection and antiretroviral therapy (ART) is not fully understood, and treatment options remain limited. Telmisartan, an angiotensin receptor blocker and partial PPAR-γ agonist, has been shown to decrease visceral fat and improve metabolic and inflammatory parameters in HIV-uninfected subjects.

Methods

HIV-infected subjects with HIV-1 RNA <50 copies/mL on ART and (women/men) waist circumference >94/95 cm or waist: hip ratio >0.88/0.94 received open-label telmisartan 40 mg po daily for 24 weeks. Adipose tissue (AT) volumes were quantified by L4–L5 single slice computed tomography. Metabolic and inflammatory markers were obtained fasting. Thirty-five subjects provided 80% power to detect a 10% 24-week decrease in visceral AT (VAT, two-sided α = 0.05).

Results

Thirty-five subjects enrolled and completed the protocol. At entry (median or %): age 49 years, 43% female, 77% non-white, 91% non-smokers, CD4+ T cell count 590 cells/mm³, BMI 31 kg/m². AT responses were heterogeneous, with statistically significant losses of median (IQR) total (TAT, 2.9% (−9.8, 0.7), p = 0.03) and subcutaneous (SAT, −2.7% (−9.8, 1.1), p = 0.03) AT, but not VAT (−2.7% (−20.5, 14.2), p = 0.53). Significant decreases in waist circumference and waist:hip ratio occurred (both p<0.001) without BMI or weight changes. In an exploratory analysis, significant increases in TNF-α occurred among female subjects without changes in other inflammatory or metabolic markers. No related adverse events occurred.

Conclusions

Telmisartan was well tolerated. Small losses of AT from all depots were observed after 24 weeks of telmisartan therapy. Further study is needed to determine whether HIV-infected patients can receive metabolic benefits from telmisartan.

Trial Registration

ClinicalTrials.gov NCT01088295

The association of epicardial adipose tissue with coronary artery calcification among HIV-infected men

Little data exist regarding the association of epicardial adipose tissue (EAT) and cardiovascular disease among HIV-infected persons. Among 213 HIV-infected men, there was a significant association between protease inhibitor use and increasing EAT volume. EAT was significantly associated with coronary artery calcium greater than 100. The elevated coronary artery disease risk in HIV-infected men may be partially explained by EAT associated with protease inhibitor use.

Cardiovascular risk estimation in 2012: lessons learned and applicability to the HIV population

Cardiovascular disease (CVD) risk assessment tools such as the Framingham Risk Functions, often called Framingham Risk Scores, are common in the evaluation of the CVD risk among individuals in the general population. These functions are multivariate risk algorithms that combine data on CVD risk factors, such as sex, age, systolic blood pressure, total cholesterol level, high-density lipoprotein cholesterol level, smoking behavior, and diabetes status, to produce an estimate (or risk) of developing CVD or a component of it (such as coronary heart disease, stroke, peripheral vascular disease, and heart failure) over a fixed period (eg, the next 10 years). These estimates of CVD risk are often major inputs in recommending drug treatments, such as agents to reduce cholesterol level. The Framingham Risk Functions are valid in diverse populations, at times requiring a calibration adjustment for proper applicability. With the realization that individuals with human immunodeficiency virus (HIV) infection often have elevated CVD risk factors, the evaluation of CVD risk for these individuals becomes a serious concern. Researchers have recently developed new CVD risk functions specifically for HIV-infected patients and have also examined the extension of existing Framingham Risk Functions to the HIV-infected population. This article first reviews briefly the Framingham Study and risk functions, covering their objectives, their components, evaluation of their performance, and transportability and validity on non-Framingham populations. It then reviews the development of CVD risk functions for HIV-infected individuals and comments on the usefulness of extending the Framingham risk equation to the HIV-infected population and the need to develop more-specific risk prediction equations uniquely tailored to this population.

Ritonavir-induced lipoatrophy and dyslipidaemia is reversed by the anti-inflammatory drug leflunomide in a PPAR-γ-dependent manner

BACKGROUND

The complex interplay between viral infection and virus-activated inflammatory pathways with protease inhibitors (PIs) contributes to the increased risk of developing atherosclerosis and coronary artery disease in HIV-infected patients. Leflunomide is an antirheumatic drug whose administration to HIV-1-infected persons effectively decreases T-cell turnover and activation. In this study we have investigated the effects of leflunomide on dyslipidaemia and lipodistrophy induced by ritonavir in rodents.

METHODS

Mice were administered ritonavir (5 mg/kg/day) alone or in combination with leflunomide (40 mg/kg/day) for 12 days. Expression of nuclear receptor and lipidogenetic genes was measured in liver and adipose tissues.

RESULTS

Administration of the HIV PI ritonavir to mice increased plasma triacylglycerols, free fatty acids and cholesterol levels, and this effect was reverted by cotreatment with leflunomide. Ritonavir administration was associated with reduced epididymal fat/body weight ratio and increased liver content of triacylglycerols content. These effects were reverted by leuflunomide. Histopathology analysis shows that exposure to ritonavir causes inflammation of epididymal fat as demonstrated by dense leukocytes infiltration as well as by increased levels of proinflammatory mediators and reduced expression and activity of peroxisome proliferator-activated receptor-γ (PPAR-γ). Leflunomide reduced epididymal fat inflammatory-metabolic alteration induced by ritonavir and restored PPAR-γ expression in the epididymal fat.

CONCLUSIONS

We have shown that the anti-inflammatory drug leflunomide protects against ritonavir-induced inflammation and dysmetabolism in adipose tissue and might be a promising strategy in the setting of HIV-infected patients at risk for HIV-induced dyslipidaemia.

Nutritional and metabolic correlates of cardiovascular and bone disease in HIV-infected patients

The treatment of HIV infection has dramatically reduced the incidence of AIDS-related illnesses. At the same time, non-AIDS-related illnesses such as cardiovascular and bone disease are becoming more prevalent in this population. The mechanisms of these illnesses are complex and are related in part to the HIV virus, antiretroviral medications prescribed for HIV infection, traditional risk factors exacerbated by HIV, and lifestyle and nutritional factors. Further prospective research is needed to clarify the mechanisms by which HIV, antiretroviral medications, and nutritional abnormalities contribute to bone and cardiovascular disease in the HIV population. Increasingly, it is being recognized that optimizing the treatment of HIV infection to improve immune function and reduce viral load may also benefit the development of non-AIDS-related illnesses such as cardiovascular and bone disease.

Human immunodeficiency virus endocrinopathy

Human immunodeficiency virus (HIV) endocrinopathy encompasses a broad spectrum of disorders. Almost all the endocrine organs are virtually affected by HIV infection. HIV can directly alter glandular function. More commonly secondary endocrine dysfunction occurs due to opportunistic infections and neoplasms in immunocompromised state. The complex interaction between HIV infection and endocrine system may be manifested as subtle biochemical and hormonal perturbation to overt glandular failure. Antiretroviral therapy as well as other essential medications often result in adverse endocrinal consequences. Apart from adrenal insufficiency, hypogonadism, diabetes and bone loss, AIDS wasting syndrome and HIV lipodystrophy need special reference. Endocrinal evaluation should proceed as in other patients with suspected endocrine dysfunction. Available treatment options have been shown to improve quality of life and long-term mortality in AIDS patients.

Regional fat deposition and cardiovascular risk in HIV infection: the FRAM study

HIV-infected individuals are at increased risk for cardiovascular disease (CVD) and lipodystrophy, but the relationship between regional adipose tissue (AT) depots and CVD risk is not well described. We determined regional AT volumes and CVD risk in an analysis of 586 HIV-infected and 280 control FRAM study subjects using whole-body magnetic resonance imaging (MRI) and the Framingham Risk Score (FRS). Median FRS and FRS >10% were higher in HIV than control men (4.7% vs. 3.7%, p=0.0002; 16% vs. 4%, p<0.0001). HIV and control women had similarly low FRS (1.1% vs. 1.2%, p=0.91). In controls, total AT and all regional AT depots showed strong positive correlations with FRS (p<0.001) in men and weaker positive correlations in women. Greater visceral AT (VAT) and lower leg subcutaneous AT (SAT) volumes were associated with elevated FRS in HIV subjects with a trend for upper trunk SAT. Controls in the lowest quartile of leg SAT had the lowest FRS (1.5%), whereas HIV with similarly low leg SAT had the highest FRS (4.0%, p<0.001 vs. controls). Increased VAT is associated with CVD risk, but the risk is higher in HIV-infected individuals relative to controls at every level of VAT. Peripheral lipoatrophy (as measured by leg SAT) is associated with striking increased CVD risk in HIV-infected patients even after controlling for VAT, whereas low leg SAT is associated with low CVD risk in controls.

Role of biomarkers in predicting CVD risk in the setting of HIV infection?

PURPOSE OF REVIEW

The purpose of this review is to present recent results on biomarkers and risk of cardiovascular disease (CVD) in the general population and to review studies of biomarkers among individuals with HIV infection.

RECENT FINDINGS

Several inflammatory as well as lipid biomarkers are associated with risk of CVD. Biomarkers associated with inflammation such as C-reactive protein and interleukin-6 have been suggested to improve risk stratification among intermediate-risk persons; however, their routine use is not recommended in the general population. Both biomarkers have recently been reported elevated in patients with HIV. Additionally, interleukin-6 and D-dimer have been reported to predict overall mortality among individuals with HIV. However, the utility of other biomarkers to predict CVD among individuals with HIV infection is not clear.

SUMMARY

The risk of CVD is increasing in the HIV-infected population and will increase as this population continues to age. Identification of intermediate-risk individuals using biomarkers will be an important tool for clinicians in the future to be able to treat HIV-infected individuals aggressively. Future studies of biomarkers among individuals with HIV will be needed to help determine the utility of specific markers in predicting CVD risk as well as the mechanism underlying increased CVD risk in the setting of HIV infection.

Switching antiretroviral therapy to minimize metabolic complications

Advances in HIV therapy have made living with HIV for decades a reality for many patients. However, antiretroviral therapy has been associated with multiple long-term complications, including dyslipidemia, fat redistribution, insulin resistance and increased cardiovascular risk. As newer agents with improved metabolic profiles have become available, there is growing interest in the safety and efficacy of switching ART as a strategy to reduce long-term complications. This article reviews recently published data on switching ART to minimize the contributions of specific agents to these complications.

Comparison between the Framingham and prospective cardiovascular of Münster scores for risk assessment of coronary heart disease in human immunodeficiency virus-positive patients in Pernambuco, Brazil

BACKGROUND

The Framingham score is used in most studies on human immunodeficiency virus (HIV)-positive patients to estimate the risk for coronary heart disease; however, it may have some limitations for detecting risk among these individuals.

OBJECTIVE

The aim of this study was to evaluate the agreement between the Framingham and Prospective Cardiovascular of Münster (PROCAM) scores among HIV-positive individuals and to investigate the factors associated with disagreement between the two scores.

METHOD

A cross-sectional study was conducted in a population of HIV/acquired immunodeficiency syndrome (AIDS) patients attending the outpatient's clinics of two reference centers for HIV/AIDS in Pernambuco, Brazil. Agreement between the Framingham and PROCAM scores was evaluated using the kappa index. From this analysis, a variable called "disagreement between scores" was created, and univariate and multivariate analysis were performed to investigate the factors associated with this variable.

RESULTS

The prevalence of low, moderate, and high risk were, respectively, 78.7%, 13.5%, and 7.8% by Framingham score and 88.5%, 4.3%, and 7.2% by PROCAM (kappa = 0.64, P ≤ 0.0001). Agreement in the subgroup with metabolic syndrome by the International Diabetes Federation (IDF) (kappa = 0.51, P ≤ 0.0001) and the National Cholesterol Education Program (NCEP) (kappa = 0.59, P ≤ 0.0001) criteria was moderate. The Framingham score identified greater proportion of women with moderate risk. Factors independently associated with disagreement were: smoking, sex, age, low-density lipoprotein cholesterol, diastolic blood pressure, and metabolic syndrome.

CONCLUSION

There was a good agreement between the Framingham and PROCAM scores in HIV-positive patients, but a higher proportion of moderate-high risk was identified by the Framingham score. This disagreement should be evaluated in cohort studies to observe clinical outcomes over the course of time.

The efficacy and safety of insulin-sensitizing drugs in HIV-associated lipodystrophy syndrome: a meta-analysis of randomized trials

Background

HIV-associated lipodystrophy syndrome (HALS) is characterized by insulin resistance, abnormal lipid metabolism and redistribution of body fat. To date, there has been no quantitative summary of the effects of insulin sensitizing-agents for the treatment of this challenging problem.

Methods

We searched MEDLINE, the Cochrane Library, clinical trial registries, conference proceedings and references for randomized trials evaluating rosiglitazone, pioglitazone or metformin in patients with evidence of HALS (last update December 2009). Two reviewers independently abstracted data and assessed quality using a standard form. We contacted authors for missing data and calculated weighted mean differences (WMD) and 95% confidence intervals (CI) for each outcome.

Results

Sixteen trials involving 920 patients met inclusion criteria. Rosiglitazone modestly improved fasting insulin (WMD -3.67 mU/L; CI -7.03, -0.31) but worsened triglycerides (WMD 32.5 mg/dL; CI 1.93, 63.1), LDL (WMD 11.33 mg/dL; CI 1.85, 20.82) and HDL (WMD -2.91 mg/dL; CI -4.56, -1.26) when compared to placebo or no treatment in seven trials. Conversely, pioglitazone had no impact on fasting insulin, triglycerides or LDL but improved HDL (WMD 7.60 mg/dL; CI 0.20, 15.0) when compared to placebo in two trials. Neither drug favorably impacted measures of fat redistribution. Based on six trials with placebo or no treatment controls, metformin reduced fasting insulin (WMD -8.94 mU/L; CI -13.0, -4.90), triglycerides (WMD -42.87 mg/dL; CI -73.3, -12.5), body mass index (WMD -0.70 kg/m²; CI -1.09, -0.31) and waist-to-hip ratio (WMD -0.02; CI -0.03, 0.00). Three trials directly compared metformin to rosiglitazone. While effects on insulin were comparable, lipid levels and measures of fat redistribution all favored metformin. Severe adverse events were uncommon in all 16 trials.

Conclusion

Based on our meta-analysis, rosiglitazone should not be used in HALS. While pioglitazone may be safer, any benefits appear small. Metformin was the only insulin-sensitizer to demonstrate beneficial effects on all three components of HALS.

Coronary heart disease risk assessment in HIV-infected patients: a comparison of Framingham, PROCAM and SCORE risk assessment functions

OBJECTIVES

The aim of this was to compare the performance of the Framingham, Systematic Coronary Risk Evaluation (SCORE) and Prospective Cardiovascular Munster (PROCAM) scoring systems in the risk assessment of HIV-infected patients with no overt vascular disease.

METHODS

A cross-sectional study of 220 HIV-infected patients was conducted at the outpatient clinic of a referral and training centre in infectious and parasitic diseases in Belo Horizonte, Brazil. The Framingham, SCORE and PROCAM equations were calculated. Patients were classified as having low, moderate or high risk, which according to the Framingham and PROCAM equations corresponded to < 10%, 10-20% and > 20% respectively, and according to SCORE corresponded to < 3%, 3-4% and > or = 5% respectively. Cohen's kappa coefficient was used to assess agreement between the methods.

RESULTS

Of a total of 220 HIV-infected patients, 56 were antiretroviral (ARV)-naïve while 164 had already been treated with ARV. The prevalence of patients with a high 10-year cardiovascular risk was 3.7%, 2.5% and 1.9% according to the Framingham, PROCAM and SCORE equations respectively. The degree of agreement was moderate between the Framingham and PROCAM risk estimates (kappa = 0.433; p < 0.001), poor-to-fair between the Framingham and SCORE estimates (kappa = 0.220; p < 0.001) and moderate between the PROCAM and SCORE systems (kappa = 0.478; p < 0.001).

CONCLUSIONS

There are differences in risk assessment and in the identification of high risk individuals between the three risk functions under evaluation and only a prospective study will be capable of assessing which offers the best current sensitivity, specificity and predictive values for the population under investigation.

Cardiovascular complications in HIV-infected individuals

PURPOSE OF REVIEW

This review updates the relationship between HIV and cardiovascular abnormalities in the context of the pathophysiology of coronary artery disease.

RECENT FINDINGS

The evaluation of cardiovascular risk in patients with HIV hinges upon a complex interplay of direct and indirect vascular effects of HIV infection, antiretroviral therapy, aging, and exposure to cardiovascular risk factors. Carotid artery intima-media thickness and endothelial-dependent flow-mediated vasodilatation of the brachial artery, which gives an indication of the structural and functional aspect of the endothelium as well as soluble biomarkers, can help to assess the potential harm and benefits of antiretroviral drugs and address the residual burden of cardiovascular risk in the HIV population.

SUMMARY

Given the complex pathophysiology of cardiovascular disease, no single biomarker is likely to be able to provide a universal surrogate whereby change observed independently predicts benefit, increased risk, or no effect across all drugs and mechanistic targets. Investigations and treatments must be tailored in the single patient according to non-modifiable and modifiable risk factors, including exposure to highly active antiretroviral therapy. With proper risk stratification altering the approach to highly active antiretroviral therapy, lifestyle changes, and lipid-lowering medications are the basis for reducing cardiovascular risk in HIV-infected patients.

Understanding and managing the adverse effects of antiretroviral therapy

Highly active antiretroviral therapy (HAART) has changed the landscape of HIV disease in a way that seemed unthinkable a decade ago; from an almost uniformly fatal disease to a chronic manageable one. The first HAART regimens worked in suppressing virus, but were encumbered by a variety of short term and long term side effects. More recent regimens became simpler, easier to take, and with fewer adverse events. As we look to people living perhaps a normal life span with HIV, the increasing number of antiretroviral agents available means that individualizing treatment has become more feasible and the longer downstream adverse events related to HAART, such as its effect on cardiovascular disease and diabetes, renal and hepatic disease, have begun to dominate our choice of drugs. A knowledge of both the short and long term adverse events associated with HAART is essential for providers and for patients. For new drugs to be acceptable in the current field, they will have to pass a litmus test of tolerability. Since adverse events are often remarkably idiosyncratic, pharmacogenomics may offer a way of predicting side effects and their severity from a particular drug or drug class in individual patients. This article forms part of a special issue of Antiviral Research marking the 25th anniversary of antiretroviral drug discovery and development, Vol. 85, issue 1, 2010.

Improvement in lipid profiles over 6 years of follow-up in adults with AIDS and immune reconstitution

OBJECTIVES

The aim of the study was to evaluate long-term changes in lipids and to assess other coronary heart disease (CHD) risk factors in highly experienced AIDS patients with immune reconstitution, and to examine their association with antiretroviral therapy (ART).

METHODS

We evaluated 433 AIDS patients with prior severe immunosuppression and ART-based immune reconstitution, followed in a multicentre prospective observational study between 2000 and 2006. We estimated the prevalence at entry of hypercholesterolaemia and metabolic syndrome, and 10-year CHD risks. Trends in total cholesterol (TC), triglycerides (TG) and high-density lipoprotein (HDL) cholesterol were evaluated over time, and use of specific ART drugs at each study visit was assessed using mixed effect models, adjusting for CHD risk factors and use of lipid-lowering agents.

RESULTS

At entry to observational follow-up, 28% of the 433 subjects had hypercholesterolaemia and 15% had a predicted 10-year CHD risk above 20%. Average TC and fasting TG levels declined over the follow-up period (median=5.8 years), and these declines were associated with increased use of physician-prescribed lipid-lowering agents and changes in ART regimens. After adjustment for CHD risk factors, TC and TG levels were significantly higher for those on ritonavir-boosted protease inhibitors and those on nonnucleoside reverse transcriptase inhibitors (NNRTIs), particularly efavirenz, than for other patients.

CONCLUSIONS

Abnormalities in serum lipids were common at baseline but became less so over time, and this improvement was associated with increased use of lipid-lowering agents and selection of ART agents with less deleterious effects on lipids.

Endothelial activation markers are linked to HIV status and are independent of antiretroviral therapy and lipoatrophy

OBJECTIVES

To assess the association of inflammatory and endothelial activation biomarkers with the presence of lipoatrophy in HIV-infected subjects and to examine the role of HIV, antiretroviral therapy (ART), and metabolic parameters in endothelial activation and inflammation.

DESIGN

Prospective, cross-sectional study including 4 groups: HIV+ on ART with HIV-1 RNA<1000 copies/mL with and without clinical lipoatrophy, HIV+ ART naive, and healthy controls.

METHODS

We measured plasma levels of inflammatory cytokines (tumor necrosis factor-alpha, soluble tumor necrosis factor receptors I and II, interleukin-6, C-reactive protein, and myeloperoxidase) and endothelial activation markers (soluble intercellular and vascular cell adhesion molecules and von Willebrand factor).

RESULTS

We enrolled 182 subjects. Limb fat and lipoatrophy status were not correlated with endothelial markers. Endothelial markers were higher in HIV+ ART naive when compared with healthy controls and with HIV+ on ART but were similar between HIV+ on ART and healthy controls. Neither endothelial nor inflammatory markers were correlated with HIV duration, CD4 count, lipids, glucose, or specific ART. Strong correlations were found between some inflammatory cytokines and endothelial markers.

CONCLUSIONS

There is enhanced endothelial activation in ART naive, whereas HIV+ on ART has similar values to healthy controls. Lipoatrophy did not seem to affect endothelial activation. Results highlight a potential association between heightened inflammation and endothelial activation.

Treatment options for HIV-associated central fat accumulation

Central fat accumulation is increasingly recognized as a problem for patients with HIV infection. The term "lipodystrophy" has been used to describe collectively a constellation of body habitus changes and metabolic abnormalities commonly observed in HIV-infected patients, particularly since the advent of highly active antiretroviral therapy. Visceral fat accumulation can place patients at increased risk of coronary artery disease.Furthermore, body shape changes are a source of distress to patients that may compromise treatment adherence.Reduction of abdominal obesity can therefore be considered part of therapy in HIV-positive patients with visceral adipose tissue (VAT) accumulation. Currently, there are no drugs approved by the Food and Drug Administration for the treatment of HIV-associated central fat accumulation. Lifestyle modifications such as diet and exercise and switching antiretroviral therapies appear to be of limited value in reducing VAT. Metformin has shown some benefit in reducing VAT but at the expense of accelerating peripheral fat loss, and the thiazolidinediones have no effect on VAT. Similarly, testosterone does not appear to reduce VAT in these patients,and there are no data on anabolic steroids. Two large, randomized controlled trials have demonstrated the efficacy of recombinant human growth hormone (rhGH) in reducing visceral adipose tissue. There are also promising data regarding treatment with growth hormone releasing hormone (GHRH).

Growth and puberty in children with HIV infection

Children with perinatal HIV infection may present with clinical features of endocrine dysfunction such as growth failure and pubertal delay. Pediatric care providers and pediatric endocrinologists should implement appropriate preventive, screening, and therapeutic strategies to maximize survival and quality of life in these children. Growth and pubertal delay can be exacerbated by a variety of treatable infectious, endocrine, nutritional, and immunological disorders. Timely diagnosis and appropriate treatment of these conditions may lead to improvement or even normalization of growth and puberty. HIV-infected children with advanced disease should undergo periodic growth evaluation, including GH levels, IGF-I, IGF binding protein 3 and androgens, in order to identify subclinical endocrine dysfunction. However, little is known about the association between HIV infection and endocrine dysfunction in children. Highly active antiretroviral therapy may also be associated with endocrine dysfunction with consequences on growth and puberty. Growth retardation and pubertal delay are always seen in children with advanced HIV infection and are often related to the proinflammatory milieu found in advanced AIDS. Growth and pubertal impairment are markers of advanced disease and require proper evaluation. A dysregulation of the hypothalamic-pituitary axis, toxic or allergic drug reactions may play a role in growth and pubertal delay of HIV-infected children. These dysfunctions require careful monitoring, in order to assess metabolic alterations that may be important in regulation of growth among HIV infected children. Better understanding of the mechanisms leading to impairment of growth and puberty in children with perinatal HIV-1 infection might lead to appropriate treatment when required.

Evaluation of high-protein supplementation in weight-stable HIV-positive subjects with a history of weight loss: a randomized, double-blind, multicenter trial

BACKGROUND

HIV patients with wasting are at increased risk of opportunistic complications and fatality.

OBJECTIVE

We hypothesized that augmenting dietary intake with high-biologic-value protein would enhance weight and lean tissue in weight-stable subjects with a prior unintentional weight loss of >3%.

DESIGN

Fifty-nine subjects with HIV RNA concentrations <5000 copies/mL were randomly assigned to receive a 280-kcal supplement containing 40 g whey protein or a matched isocaloric control supplement without added protein twice daily for 12 wk.

RESULTS

Before the study, intake of total energy and protein exceeded estimated requirements (44.3 +/- 12.6 kcal x kg(-1) x d(-1) and 1.69 +/- 0.55 g x kg(-1) x d(-1), respectively). Both supplements failed to increase total energy intake because of decreases in self-selected food intake. Changes in weight (0.8 +/- 2.4 and 0.7 +/- 2.4 kg) and lean body mass (0.3 +/- 1.4 and 0.3 +/- 1.5 kg) did not differ significantly between the whey protein and control groups, respectively. Waist-to-hip ratio improved more with whey protein (-0.02 +/- 0.05) than with the control (0.01 +/- 0.03; P = 0.025) at week 6 but not at week 12. Fasting triacylglycerol increased by 39 +/- 98 mg/dL with the control supplement and decreased by 16 +/- 62 mg/dL with whey protein at week 12 (P = 0.03). CD4 lymphocytes increased by 31 +/- 84 cells/mm(3) with whey protein and decreased by 5 +/- 124 cells/mm(3) with the control supplement at 12 wk (P = 0.03). Gastrointestinal symptoms occurred more often with whey protein.

CONCLUSIONS

A whey protein supplement did not increase weight or lean body mass in HIV-positive subjects who were eating adequately, but it did increase CD4 cell counts. The control supplement with rapidly assimilable carbohydrate substituted for protein increased cardiovascular disease risk factors. Careful dietary and weight history should be obtained before starting nutritional supplements in subjects with stable weight loss and good viral control.

Prevalence and predictors of metabolic syndrome among HIV-infected and HIV-uninfected women in the Women's Interagency HIV Study

OBJECTIVES

To assess the prevalence of metabolic syndrome (MetSynd) among participants of the Women's Interagency HIV Study and to describe the association of MetSynd with HIV infection, antiretroviral therapies, and sociodemographic factors.

METHODS

Prevalence of MetSynd, defined by updated Adult Treatment Panel III guidelines, was assessed among 2393 (1725 seropositive and 668 seronegative) participants from the Women's Interagency HIV Study seen between October 2000 and October 2004.

RESULTS

HIV-1 infection was independently associated with MetSynd [33% vs 22%, P<0.0001 in HIV-seropositive compared with HIV-seronegative women; adjusted odds ratio (OR) 1.79 (95% confidence interval 1.48, 2.16)]. HIV-infected women had higher mean triglyceride (154 vs 101 mg/dL, P<0.0001) and lower mean high-density lipoprotein cholesterol levels (46 vs 55 mg/dL, P<0.0001). Most notable factors associated with higher prevalence of MetSynd among HIV-infected women included older age (OR=1.38 per 5 year increase, P<0.0001); higher body mass index; current smoking; HIV-1 RNA (OR=1.36, P=0.019, for >50,000 vs <80 copies/mL); and use of stavudine (OR=1.28, P=0.009). Nevirapine use was protective (OR=0.75, P=0.016). There was no significant association of MetSynd with ritonavir-boosted protease inhibitors (OR=1.15, P=0.134).

CONCLUSIONS

MetSynd is more prevalent in HIV-seropositive than HIV-seronegative women. This increased prevalence was due to dyslipidemias rather than higher blood pressure, glucose, or waist circumference.

Comparability of echographic and tomographic assessments of body fat changes related to the HIV associated adipose redistribution syndrome (HARS) in antiretroviral treated patients

To assess the comparability of ultrasonographic (US) subcutaneous fat thickness (SFT) measurements in comparison with computed tomography (CT) at reference points (RPs) representative of HIV related adipose redistribution syndrome (HARS) in patients treated with antiretrovirals. US and CT measurements were compared in nine patients with clinical reports of HARS. We obtained the best resolution of facial (at deepest point of Bichat pad), brachial (in the dorsal face of arm) and crural SFT (at mid thigh) by means of minimal transducer pressures avoiding potential biases such as stand off pads pressure on the skin and artefacts due to too abundant quantity of gel. CT scans were obtained in the same RP where US measurements were performed such as identified by means of metallic skin markers. Median US measurement of facial SFT was 8.8 mm (95% CI: 3.1 to 13.4), 3.95 mm (95% CI: 2.62 to 5.84) for brachial SFT and 4 mm (95% CI: 3.4 to 9.4) for crural SFT. Median CT assessments of facial SFT was 8.7 mm (95% CI: 3.5 to 13.5), 4.2 mm (95% CI: 2.6 to 5.88) for brachial SFT and 5 mm (95% CI: 3.9 to 10.3) for crural SFT, with no significant difference at each RP. A linear regression showed good CT/US comparability at each RP, with no significant deviation from linearity (p > 0.10). US shows to be highly comparable with CT, excluding invaliding biases as the transducer pressure on the skin. Given the proven efficacy on the HARS assessments, if well standardized, US could be a reliable method, simpler than CT in the management of body fat changes related to HARS.

A randomized placebo-controlled trial of metformin for the treatment of HIV lipodystrophy

OBJECTIVE

We conducted a randomized placebo-controlled trial to examine the effects of metformin on visceral adipose tissue (VAT), appendicular fat, lipid profile and insulin sensitivity in HIV-infected persons with central adiposity and mild insulin resistance.

METHODS

Forty-eight HIV-infected men and women with a self-reported increase in abdominal girth and an abnormal waist-to-hip ratio were randomly assigned in double-blind fashion to receive metformin 1500 mg or placebo daily for 24 weeks. Persons with diabetes were excluded. The following measures were obtained at baseline and 24 weeks: single-slice computed tomography (CT) scan, dual-energy X-ray absorptiometry (DEXA), lipid profile and oral glucose tolerance test.

RESULTS

The median fasting insulin concentration of all participants was 12.3 microU/mL. The percentage change in VAT was not significantly different between the metformin and placebo groups in univariate analysis and linear regression analysis adjusting for age, height, baseline VAT and insulin area under the curve (10.1% vs 3.2%; P=0.58). Metformin was associated with a significant decrease in appendicular fat mass compared with placebo (-686.0 vs 161.0 g; P=0.03). There was no significant change in lipid profile or insulin sensitivity between the two groups at 24 weeks.

CONCLUSION

Metformin should be used with caution in the treatment of HIV lipodystrophy, and, if used, should be reserved for persons with adequate peripheral fat and marked insulin resistance.