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Ramirez Bustamante CE, Agarwal N, Cox AR, Hartig SM, Lake JE, Balasubramanyam A. Adipose Tissue Dysfunction and Energy Balance Paradigms in People Living With HIV. Endocr Rev 2024; 45:190-209. [PMID: 37556371 PMCID: PMC10911955 DOI: 10.1210/endrev/bnad028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 07/09/2023] [Accepted: 08/07/2023] [Indexed: 08/11/2023]
Abstract
Over the past 4 decades, the clinical care of people living with HIV (PLWH) evolved from treatment of acute opportunistic infections to the management of chronic, noncommunicable comorbidities. Concurrently, our understanding of adipose tissue function matured to acknowledge its important endocrine contributions to energy balance. PLWH experience changes in the mass and composition of adipose tissue depots before and after initiating antiretroviral therapy, including regional loss (lipoatrophy), gain (lipohypertrophy), or mixed lipodystrophy. These conditions may coexist with generalized obesity in PLWH and reflect disturbances of energy balance regulation caused by HIV persistence and antiretroviral therapy drugs. Adipocyte hypertrophy characterizes visceral and subcutaneous adipose tissue depot expansion, as well as ectopic lipid deposition that occurs diffusely in the liver, skeletal muscle, and heart. PLWH with excess visceral adipose tissue exhibit adipokine dysregulation coupled with increased insulin resistance, heightening their risk for cardiovascular disease above that of the HIV-negative population. However, conventional therapies are ineffective for the management of cardiometabolic risk in this patient population. Although the knowledge of complex cardiometabolic comorbidities in PLWH continues to expand, significant knowledge gaps remain. Ongoing studies aimed at understanding interorgan communication and energy balance provide insights into metabolic observations in PLWH and reveal potential therapeutic targets. Our review focuses on current knowledge and recent advances in HIV-associated adipose tissue dysfunction, highlights emerging adipokine paradigms, and describes critical mechanistic and clinical insights.
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Affiliation(s)
- Claudia E Ramirez Bustamante
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Neeti Agarwal
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Aaron R Cox
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Sean M Hartig
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Jordan E Lake
- Division of Infectious Diseases, Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, TX 77030, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
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Kalra DK, Vorla M, Michos ED, Agarwala A, Virani S, Duell PB, Raal FJ. Dyslipidemia in Human Immunodeficiency Virus Disease: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:171-181. [PMID: 37407116 DOI: 10.1016/j.jacc.2023.04.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/27/2023] [Accepted: 04/20/2023] [Indexed: 07/07/2023]
Abstract
The advent of newer and better tolerated antiretroviral therapy has progressively shortened the life expectancy gap between people living with HIV (PWH) and the general population. However, in this aging cohort, cardiovascular disease is now a significant cause of morbidity and mortality despite advances in cardiac care. Therefore, it is critical to assess and treat all cardiovascular disease risk factors, including dyslipidemia, early and aggressively in PWH. Data are not as robust regarding the pathogenesis and management of dyslipidemia in PWH, with most evidence being extrapolated from the general uninfected population. In this review the authors describe the current understanding of the pathophysiology of HIV and antiretroviral therapy-induced dyslipidemia, and the approach to risk assessment and management, given that drug-drug interactions remain an important consideration in this population.
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Affiliation(s)
- Dinesh K Kalra
- Division of Cardiology, University of Louisville, Louisville, Kentucky, USA.
| | - Mounica Vorla
- Division of Cardiology, University of Louisville, Louisville, Kentucky, USA
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anandita Agarwala
- Center for Cardiovascular Disease Prevention, Baylor Scott & White Health, Plano, Texas, USA
| | - Salim Virani
- Section of Cardiovascular Research, Baylor College of Medicine and Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - P Bart Duell
- Division of Cardiovascular Medicine, Oregon Health Sciences University, Portland, Oregon, USA
| | - Frederick J Raal
- Division of Endocrinology & Metabolism, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
PURPOSE OF REVIEW While people with HIV (PWH) are living longer due to advances in antiretroviral therapy, recent data have demonstrated an increased risk of cardiovascular disease (CVD) among this population. This increased risk is thought to be due to both traditional (for example, smoking, diabetes) and HIV-specific (for example, inflammation, persistent immune activation) risk factors. This review focuses on the potential for statin therapy to mitigate this increased risk. RECENT FINDINGS Several randomized clinical trials have demonstrated that statins, a class of lipid-lowering medications, are effective as a primary CVD prevention strategy among people without HIV. Among PWH, statins have been shown to lower cholesterol, exert immunomodulatory effects, stabilize coronary atherosclerotic plaque, and even induce plaque regression. SUMMARY Prevention of CVD among the aging population of people with controlled, but chronic, HIV is vital. Data exploring primary prevention in this context are thus far limited. The Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) is ongoing; this trial will inform the field by investigating the effects of pitavastatin calcium as a primary prevention strategy for major adverse cardiovascular events among PWH on antiretroviral therapy (ART) at low-to-moderate traditional CVD risk.
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Li Y, Wang Z, Xia H, Zhang J. Influence of Statin Therapy on the Incidence of Cardiovascular Events, Cancer, and All-Cause Mortality in People Living With HIV: A Meta-Analysis. Front Med (Lausanne) 2021; 8:769740. [PMID: 34820402 PMCID: PMC8606632 DOI: 10.3389/fmed.2021.769740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/29/2021] [Indexed: 01/19/2023] Open
Abstract
Background: Possible influences of statin therapy on the risk of cardiovascular events, cancer, and all-cause mortality in people living with HIV (PLWH) remain unclear. We performed a meta-analysis to systematically evaluate the efficacy of statin in PLWH. Methods: Relevant cohort studies were retrieved via a search of the Medline, the Embase, and the Web of Science databases until June 14, 2021. The data were combined with a random-effects model by incorporating the between-study heterogeneity. Results: A total of 12 multivariate cohort studies with 162,252 participants were eligible for the meta-analysis and 36,253 (22.3%) of them were statin users. Pooled results showed that statin use was independently related to a reduced mortality risk in PLWH [adjusted risk ratio (RR): 0.56, 95% CI: 0.44 to 0.72, p < 0.001, I2 = 41%]. In addition, results of the meta-analysis showed that statin use was not significantly associated with a reduced risk of cardiovascular events in PLWH compared to the statin non-users (RR: 1.14, 95% CI: 0.80 to 1.63, p = 0.48, I2 = 42%). However, statin use was significantly related to a reduced risk of cancer in PLWH (RR: 0.73, 95% CI: 0.58 to 0.93, p = 0.009, I2 = 49%). Sensitivity analyses by excluding one study at a time showed consistent results. No significant publication biases were observed. Conclusion: Statin use is associated with reduced all-cause mortality in PLWH. In addition, statin use is related to a reduced risk of cancer, although the risk of cardiovascular events seems not significantly affected.
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Affiliation(s)
- Yanping Li
- School of Chemistry, Biology and Environment, Institute of Biology and Environmental Engineering, Yuxi Normal University, Yuxi, China
| | - Zhandi Wang
- School of Chemistry, Biology and Environment, Institute of Biology and Environmental Engineering, Yuxi Normal University, Yuxi, China
| | - Haimei Xia
- Center of Chinese Medicine, Yunnan Institute of Traditional Chinese Medicine, Kunming, China
| | - Ju Zhang
- Center of Chinese Medicine, Yunnan Institute of Traditional Chinese Medicine, Kunming, China
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Pyarali F, Iordanov R, Ebner B, Grant J, Vincent L, Toirac A, Haque T, Zablah G, Kapoor K, Powell A, Boulanger C, Hurwitz B, Alcaide M, Martinez C. Cardiovascular disease and prevention among people living with HIV in South Florida. Medicine (Baltimore) 2021; 100:e26631. [PMID: 34260554 PMCID: PMC8284739 DOI: 10.1097/md.0000000000026631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/23/2021] [Indexed: 01/04/2023] Open
Abstract
Antiretroviral therapy (ART) has improved survival of patients living with HIV (PLWH); however, this has been accompanied by an increase in cardiovascular disease (CVD). Although preventative measures for CVD among the general population are well described, information is limited about CVD prevention among PLWH. The goal of this study was to characterize the prevalence of CVD in our population and to assess the use of primary and secondary prevention.We performed a retrospective review of PLWH receiving primary care at a large academic center in Miami, Florida. We characterized the prevalence of CVD, CVD risk, and the use of aspirin and statins for primary and secondary CVD prevention.A total of 985 charts were reviewed (45% women, 55% men). Average age was 52.2 years. Average CD4 count was 568 cells/microL. 92.9% were receiving ART, and 71% were virologically suppressed. The median 10-year ASCVD risk was 7.3%. The prevalence of CVD was 10.4% (N = 102). The odds of having CVD was lower in patients on ART (OR 0.47, 95% CI: 0.25-0.90, P = .02). The use of medications for primary and secondary prevention of CVD based on current guidelines was low: 15% and 37% for aspirin respectively, and 25% and 44% for statins.CVD risk and rates of CVD are high among PLWH and receiving ART could protect against CVD. However, the use of medications for primary and secondary prevention is low. Increased awareness of CVD risk-reduction strategies is needed among providers of PLWH to decrease the burden of CVD.
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Affiliation(s)
- Fahim Pyarali
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Roumen Iordanov
- Department of Infectious Diseases, Baylor College of Medicine, Houston, TX
| | - Bertrand Ebner
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Jelani Grant
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Louis Vincent
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Alexander Toirac
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Tahir Haque
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Gerardo Zablah
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Kunal Kapoor
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | | | - Claudia Martinez
- Department of Cardiology, University of Miami Miller School of Medicine, Miami, FL
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Bratt G, Brännström J, Missalidis C, Nyström T. Development of type 2 diabetes and insulin resistance in people with HIV infection: Prevalence, incidence and associated factors. PLoS One 2021; 16:e0254079. [PMID: 34191847 PMCID: PMC8244855 DOI: 10.1371/journal.pone.0254079] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 06/21/2021] [Indexed: 12/12/2022] Open
Abstract
Background Diabetes and insulin resistance is an emerging issue in people with HIV. HIV-related mortality and morbidities have decreased markedly over the last few decades, while co-morbidities including type 2 diabetes (T2D) have increased. Setting This study investigated the incidence of T2D and insulin resistance in a cohort of HIV-patients on effective treatment. Methods Prevalence and baseline predictors of T2D were assessed in a cohort of 570 HIV-positive patients 50 years or older. Patients without diabetes (n = 505) were followed prospectively over a median period of 7.25 year (2012–2020) until T2D development, death or end of the study. T2D was defined as repeated fasting glucose values ≥7.0 mmol/L. Insulin resistance was defined as HOMA-IR ≥3.0. Predictors of T2D development (HIV-related parameters, lipids, hypertension, central obesity, inflammation, smoking and use of statins) were assessed using logistic regression analysis. Results 30% (153/505) had insulin resistance. During follow up (3485 patient-years) 9% (43/505) developed T2D and 7% (36/505) insulin resistance. Thus, at follow up the prevalence of either T2D or insulin resistance was 46% (232/505). T2D incidence was 1.2/100 patient-years. In multivariate analysis, after adjustment for age, T2D development was associated with baseline insulin resistance, hypertriglyceridemia, central obesity and statin treatment, but no HIV-related factors. Conclusion The incidence of T2D in this cohort of patients with well controlled HIV-infection was high. The predictive factors associated with the development of T2D were not unique for HIV positive patients. The findings underline the importance of lifestyle changes in avoidance of T2D in people with HIV.
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Affiliation(s)
- Göran Bratt
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases/Venhälsan, South Hospital, Stockholm, Sweden
| | - Johanna Brännström
- Department of Infectious Diseases/Venhälsan, South Hospital, Stockholm, Sweden
- Division of Infection and Dermatology, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Catharina Missalidis
- Department of Infectious Diseases/Venhälsan, South Hospital, Stockholm, Sweden
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Nyström
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
- Department of Internal Medicine, South Hospital, Stockholm, Sweden
- * E-mail:
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Abdo M, Langan SJ, MaWhinney S, Sun J, Lake JE, Palella FJ, Kingsley L, Brown TT, Erlandson KM. Effect of Statin Therapy on Age-Associated Changes in Physical Function Among Men With and Without HIV in the Multicenter AIDS Cohort Study. J Acquir Immune Defic Syndr 2021; 86:455-462. [PMID: 33230030 PMCID: PMC8193908 DOI: 10.1097/qai.0000000000002579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The longer-term risks of statins on physical function among people with HIV are unclear. METHODS Longitudinal analysis of Multicenter AIDS Cohort Study men between 40 and 75 years of age with ≥2 measures of gait speed or grip strength. Generalized estimating equations with interaction terms between (1) statin use and age and (2) HIV serostatus, age, and statin use were considered to evaluate associations between statin use and physical function. Models were adjusted for demographics and cardiovascular risk factors. RESULTS Among 2021 men (1048 with HIV), baseline median age was 52 (interquartile range 46-58) years; 636 were consistent, 398 intermittent, and 987 never statin users. There was a significant interaction between age, statin, and HIV serostatus for gait speed. Among people with HIV, for every 5-year age increase, gait speed (m/s) decline was marginally greater among consistent versus never statin users {-0.008 [95% confidence interval (CI) -0.017 to -0.00007]; P = 0.048}, with more notable differences between intermittent and never users [-0.017 (95% CI -0.027 to -0.008); P < 0.001]. Similar results were observed among men without HIV. Significant differences in grip strength (kg) decline were seen between intermittent and never users [-0.53 (95% CI -0.98 to -0.07); P = 0.024] and differences between consistent and never users [-0.28 (95% CI -0.63 to 0.06); P = 0.11] were not statistically significant. CONCLUSIONS Among men with and without HIV, intermittent statin users had more pronounced declines in physical function compared with consistent and never users. Consistent statin use does not seem to have a major impact on physical function in men with or without HIV.
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Affiliation(s)
- Mona Abdo
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
| | | | - Samantha MaWhinney
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Jing Sun
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jordan E Lake
- University of Texas Health Science Center at Houston, Houston, TX
| | | | | | | | - Kristine M Erlandson
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
- Division of Infectious Diseases, School of Medicine, University of Colorado-Anschutz Medical Center, Aurora, CO
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Use of Coronary Artery Calcium Scoring to Improve Cardiovascular Risk Stratification and Guide Decisions to Start Statin Therapy in People Living With HIV. J Acquir Immune Defic Syndr 2021; 85:98-105. [PMID: 32398558 DOI: 10.1097/qai.0000000000002400] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) risk assessment remains a critical step in guiding decisions to initiate primary prevention interventions in people living with HIV (PLWH). SETTING We investigated whether coronary artery calcium (CAC) scoring allowed a more accurate selection of patients who may benefit from statin therapy, compared with current risk assessment tools alone. METHODS Cross-sectional analysis of PLWH over 50 years old who underwent CAC scoring between 2009 and 2019. Framingham Risk score (FRS), QRISK2 and D:A:D scores were calculated for each participant at the time of CAC scoring and statin eligibility determined based on current European guidelines on the prevention of CVD in PLWH. RESULTS A total of 739 patients were included (mean age 56 ± 5, 92.8% male, 84% white). Among 417 (56.4%) candidates for statin therapy based on FRS ≥10%, 174 (23.5%) had no detectable calcification (CAC = 0). Conversely, 145 (19.6%) patients with detectable calcification (CAC > 0) were identified as low-risk (FRS < 10%). When compared with FRS, CAC scoring reclassified CVD risk in 43.1% of patients, 145 (19.6%) to a higher risk group that could benefit from statin therapy and 174 (23.5%) statin candidates to a lower risk group. QRISK2 and D:A:D scores performed similarly to FRS, underestimating the presence of significant coronary calcification in 21.1% and 24.9% respectively and overestimating risk in 16.9% and 18.8% patients with CAC = 0. CONCLUSIONS Establishing a decision-model based on the combination of conventional risk tools and CAC scoring improves risk assessment and the selection of PLWH who would benefit from statin therapy.
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Drechsler H, Ayers C, Cutrell J, Arasaratnam R, Bedimo R. Consistent use of lipid lowering therapy in HIV infection is associated with low mortality. BMC Infect Dis 2021; 21:150. [PMID: 33546621 PMCID: PMC7866454 DOI: 10.1186/s12879-021-05787-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/11/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In people living with HIV (PLWH), statins may be disproportionately effective but remain underutilized. A large prospective trial in patients with low to moderate cardiovascular (ASCVD) risk will reveal whether they should be considered in all PLWH. But its effect size may not apply to real-world PLWH with higher ASCVD and mortality risk. Also, the clinical role of non-statin lipid-lowering therapy (LLT) and LLT adherence in this population is unknown. METHODS Comparative multi-level marginal structural model for all-cause mortality examining four time-updated exposure levels to LLT, antihypertensives, and aspirin in a virtual cohort of older PLWH. Incident coronary, cerebrovascular, and overall ASCVD events, serious infections, and new cancer diagnoses served as explanatory outcomes. RESULTS In 23,276 HIV-infected US-veterans who were followed for a median of 5.2 years after virologic suppression overall mortality was 33/1000 patient years: > 3 times higher than in the US population. Use of antihypertensives or aspirin was associated with increased mortality. Past LLT use (> 1 year ago) had no effect on mortality. LLT exposure in the past year was associated with a reduced hazard ratio (HR) of death: 0.59, 95% confidence interval (CI) 0.51-0.69, p < 0.0001 for statin containing LLT and 0.71 (CI: 0.54-0.93), p = 0.03 for statin-free LLT. For consistent LLT use (> 11/12 past months) the HR of death was 0.48 (CI: 0.35-0.66) for statin-only LLT, 0.34 (CI: 0.23-0.52) for combination LLT, and 0.27 (CI: 0.15-0.48) for statin-free LLT (p < 0.0001 for all). The ASCVD risk in these patients was reduced in similar fashion. Use of statin containing LLT was also associated with reduced infection and cancer risk. Multiple contrasting subgroup analyses yielded comparable results. Confounding is unlikely to be a major contributor to our findings. CONCLUSIONS In PLWH, ongoing LLT use may lead to substantially lower mortality, but consistent long-term adherence may be required to reduce ASCVD risk. Consistent non-statin LLT may be highly effective and should be studied prospectively.
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Affiliation(s)
- Henning Drechsler
- VA North Texas Health Care System, Dallas, TX, USA.
- UT Southwestern Medical Center School of Medicine, Dallas, TX, USA.
| | - Colby Ayers
- VA North Texas Health Care System, Dallas, TX, USA
| | | | - Reuben Arasaratnam
- VA North Texas Health Care System, Dallas, TX, USA
- UT Southwestern Medical Center School of Medicine, Dallas, TX, USA
| | - Roger Bedimo
- VA North Texas Health Care System, Dallas, TX, USA
- UT Southwestern Medical Center School of Medicine, Dallas, TX, USA
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Bedimo RJ, Park LS, Shebl FM, Sigel K, Rentsch CT, Crothers K, Rodriguez-Barradas MC, Goetz MB, Butt AA, Brown ST, Gibert C, Justice AC, Tate JP. Statin exposure and risk of cancer in people with and without HIV infection. AIDS 2021; 35:325-334. [PMID: 33181533 PMCID: PMC7775280 DOI: 10.1097/qad.0000000000002748] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine whether statin exposure is associated with decreased cancer and mortality risk among persons with HIV (PWH) and uninfected persons. Statins appear to have immunomodulatory and anti-inflammatory effects and may reduce cancer risk, particularly among PWH as they experience chronic inflammation and immune activation. DESIGN Propensity score-matched cohort of statin-exposed and unexposed patients from 2002 to 2017 in the Veterans Aging Cohort Study (VACS), a large cohort with cancer registry linkage and detailed pharmacy data. METHODS We calculated Cox regression hazard ratios (HRs) and 95% confidence intervals (CI) associated with statin use for all cancers, microbial cancers (associated with bacterial or oncovirus coinfection), nonmicrobial cancers, and mortality. RESULTS :The propensity score-matched sample (N = 47 940) included 23 970 statin initiators (31% PWH). Incident cancers were diagnosed in 1160 PWH and 2116 uninfected patients. Death was reported in 1667 (7.0%) statin-exposed, and 2215 (9.2%) unexposed patients. Statin use was associated with 24% decreased risk of microbial-associated cancers (hazard ratio 0.76; 95% CI 0.69-0.85), but was not associated with nonmicrobial cancer risk (hazard ratio 1.00; 95% CI 0.92-1.09). Statin use was associated with 33% lower risk of death overall (hazard ratio 0.67; 95% CI 0.63-0.72). Results were similar in analyses stratified by HIV status, except for non-Hodgkin lymphoma where statin use was associated with reduced risk (hazard ratio 0.56; 95% CI 0.38-0.83) for PWH, but not for uninfected (P interaction = 0.012). CONCLUSION In both PWH and uninfected, statin exposure was associated with lower risk of microbial, but not nonmicrobial cancer incidence, and with decreased mortality.
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Affiliation(s)
- Roger J Bedimo
- Veterans Affairs North Texas Healthcare System, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lesley S Park
- Stanford University School of Medicine, Palo Alto, California
| | - Fatima M Shebl
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Keith Sigel
- Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | | | - Kristina Crothers
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, Washington
| | | | - Matthew Bidwell Goetz
- Veterans Affairs Greater Los Angeles Healthcare System, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Adeel A Butt
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvamia
- Weill Cornell Medical College, New York, New York, USA
- Weill Cornell Medical College, Doha, Qatar
| | - Sheldon T Brown
- James J. Peters Veterans Affairs Medical Center, Bronx
- Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Cynthia Gibert
- Washington DC Veterans Affairs Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Amy C Justice
- VA Connecticut Healthcare System, West Haven
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Janet P Tate
- VA Connecticut Healthcare System, West Haven
- Yale School of Medicine, New Haven, Connecticut, USA
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11
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Implementation of Cholesterol-Lowering Therapy to Reduce Cardiovascular Risk in Persons Living with HIV. Cardiovasc Drugs Ther 2020; 36:173-186. [PMID: 32979175 DOI: 10.1007/s10557-020-07085-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
The widespread availability of highly effective antiretroviral therapies has reduced mortality from opportunistic infections in persons living with HIV (PLHIV), resulting in an increase in atherosclerotic cardiovascular disease (ASCVD) and other chronic illnesses (Samji et al. 2013). Although there has been a decline in morbidity and mortality from ASCVD in the past several decades, contemporary studies continue to report higher rates of cardiovascular events (Rosenson et al. 2020). HIV has been identified as a risk enhancer for ASCVD by multiple professional guideline writing committees (Grundy Scott et al. 2019, Mach et al. 2020); however, the utilization of cholesterol-lowering therapies in PLHIV remains low (Rosenson et al. 2018). Moreover, the use of statin therapy in PLHIV is complicated by drug-drug interactions that may either elevate or lower the blood statin concentrations resulting in increased toxicity or reduced efficacy respectively. Other comorbidities commonly associated with HIV present other challenges for the use of cholesterol-lowering therapies. This review will summarize the data on lipoprotein-associated ASCVD risk in PLHIV and discuss the challenges with effective treatment. Finally, we present a clinical algorithm to optimize cardiovascular risk reduction in this high-risk population.
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12
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A randomized pilot trial to evaluate the benefit of the concomitant use of atorvastatin and Raltegravir on immunological markers in protease-inhibitor-treated subjects living with HIV. PLoS One 2020; 15:e0238575. [PMID: 32941476 PMCID: PMC7498036 DOI: 10.1371/journal.pone.0238575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 08/18/2020] [Indexed: 01/19/2023] Open
Abstract
Objective Optimization of antiretroviral therapy and anti-inflammatory treatments, such as statins, are among the strategies aimed at reducing metabolic disorders, inflammation and immune activation in people living with HIV (PLWH). We evaluated the potential benefit of combining both strategies. Design Forty-two PLWH aged ≥40 years receiving a protease inhibitor (PI)-based regimen were randomized (1:1) to switch from PI to Raltegravir (n = 20), or to remain on PI (n = 22). After 24 weeks, all patients received atorvastatin 20mg/day for 48 weeks. Methods We analyzed plasma inflammatory as well as T-cell maturation, activation, exhaustion and senescence markers at baseline, 24 and 72 weeks, Results Plasma inflammatory markers remained unchanged. Furthermore, no major changes on T-cell maturation subsets, immunoactivation, exhaustion or immunosenescence markers in both CD4 and CD8 T cell compartments were observed. Only a modest decrease in the frequency of CD38+ CD8 T cells and an increase in the frequency of CD28-CD57+ in both CD4 and CD8 T-cell compartments were noticed in the Raltegravir-switched group. Conclusions The study combined antiretroviral switch to Raltegravir and Statin-based anti-inflammatory strategies to reduce inflammation and chronic immune activation in PLWH. Although this combination was safe and well tolerated, it had minimal impact on inflammatory and immunological markers. Clinical Trials Registration NCT02577042.
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Titanji B, Gavegnano C, Hsue P, Schinazi R, Marconi VC. Targeting Inflammation to Reduce Atherosclerotic Cardiovascular Risk in People With HIV Infection. J Am Heart Assoc 2020; 9:e014873. [PMID: 31973607 PMCID: PMC7033865 DOI: 10.1161/jaha.119.014873] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Boghuma Titanji
- Division of Infectious Diseases Emory University School of Medicine Atlanta GA
| | - Christina Gavegnano
- Center for AIDS Research Laboratory of Biochemical Pharmacology Department of Pediatrics Emory University Atlanta GA
| | - Priscilla Hsue
- Department of Cardiology Zuckerberg San Francisco General Hospital University of California-San Francisco CA
| | - Raymond Schinazi
- Center for AIDS Research Laboratory of Biochemical Pharmacology Department of Pediatrics Emory University Atlanta GA
| | - Vincent C Marconi
- Division of Infectious Diseases Emory University School of Medicine Atlanta GA.,Emory Vaccine Center Atlanta GA.,Rollins School of Public Health Emory University Atlanta GA.,Atlanta VA Medical Center Decatur GA
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14
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Vizcarra P, Guillemi S, Eyawo O, Hogg RS, Montaner JS, Bennett M. Stroke and Systemic Thromboembolism Prevention in People Living With Human Immunodeficiency Virus With Atrial Fibrillation: A Review of Its Implications for Clinical Practice. CJC Open 2019; 1:245-255. [PMID: 32159116 PMCID: PMC7063632 DOI: 10.1016/j.cjco.2019.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 06/09/2019] [Indexed: 11/17/2022] Open
Abstract
In the last few decades, types of diseases affecting people living with human immunodeficiency virus (PLHIV) have shifted as the population ages, with cardiovascular disease becoming a leading cause of death in this population. Atrial fibrillation (AF) is an increasingly common arrhythmia both in the general population and in PLHIV, with an estimated prevalence of 2% to 3% among PLHIV. Prevention of stroke and systemic thromboembolism (SSE) with antithrombotic therapy is a cornerstone of AF treatment and substantially decreases AF-related morbidity and mortality. Although updated guidelines extensively discuss this issue, they do not address the peculiarities of PLHIV. The role of human immunodeficiency virus (HIV) infection as an independent factor for SSE in individuals with AF and whether the presence of HIV should alter the threshold for SSE thromboprophylaxis are unknown. Nevertheless, a growing body of evidence describes the increasing burden of comorbidities such as hypertension and stroke in PLHIV, which predispose them to AF and SSE. In the absence of HIV-specific AF guidelines, PLHIV with AF should be comprehensively assessed for their risk of SSE and bleeding using commonly available scores despite them having been primarily validated in the non-HIV population. Both vitamin K antagonists and direct oral anticoagulants can be used in PLHIV. Addressing HIV-related comorbidities and potential drug-drug interactions with antiretrovirals is crucial to prevent SSE and reduce adverse reactions of oral anticoagulants. This review summarizes the current guidelines for SSE prevention in patients with AF and describes key considerations for their implementation among PLHIV receiving antiretroviral therapy.
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Affiliation(s)
- Pilar Vizcarra
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Department of Infectious Disease, Hospital “Gral. José de San Martín,” La Plata, Buenos Aires, Argentina
- Corresponding author: Dr Pilar Vizcarra, British Columbia Centre for Excellence in HIV/AIDS, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada. Tel.: +34-687244321.
| | - Silvia Guillemi
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Department of Family Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Oghenowede Eyawo
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health, York University, Toronto, Ontario, Canada
| | - Robert S. Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Julio S. Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew Bennett
- Vancouver Coastal Health, Vancouver, British Columbia, Canada
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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15
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Waters DD, Hsue PY. Lipid Abnormalities in Persons Living With HIV Infection. Can J Cardiol 2018; 35:249-259. [PMID: 30704819 DOI: 10.1016/j.cjca.2018.11.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 01/16/2023] Open
Abstract
Lipid abnormalities are prevalent among persons living with HIV infection and contribute to increasing the risk of cardiovascular events. Antiretroviral therapy (ART) is associated with lipid abnormalities, most commonly hypertriglyceridemia, but also increases in low-density lipoprotein cholesterol and total cholesterol. Different classes of ART, and different drugs within classes, have differing effects on lipid levels, but in general newer drugs have more favourable effects compared with older ones. Low-level inflammation and chronic immune activation act on lipids through a variety of mechanisms to make them more atherogenic. As a consequence, risk is higher than would be expected for any given cholesterol level. Clinical outcome trials of cholesterol-lowering therapies have not yet been completed in people living with HIV, so that treatment decisions depend on extrapolation from studies in uninfected populations. Traditional risk assessment tools underestimate cardiovascular risk in individuals with HIV. Statins are the mainstay of lipid-lowering drug treatment; however, drug-drug interactions with ART must be considered. Simvastatin and lovastatin are contraindicated in patients taking protease inhibitors, and the dose of atorvastatin and rosuvastatin should be limited to 40 mg and 10 mg/d with some ART combinations. Switching from older forms of ART to lipid-friendly newer ones is a useful strategy as long as virologic suppression is maintained, but adding a statin lowers low-density lipoprotein cholesterol more effectively. Studies indicate that lipid abnormalities are not treated as aggressively in individuals living with HIV as they are in uninfected people, making this an opportunity to improve care.
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Affiliation(s)
- David D Waters
- Division of Cardiology, Zuckerberg San Francisco General Hospital, and Department of Medicine, University of California, San Francisco, California, USA.
| | - Priscilla Y Hsue
- Division of Cardiology, Zuckerberg San Francisco General Hospital, and Department of Medicine, University of California, San Francisco, California, USA
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16
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Uthman OA, Nduka C, Watson SI, Mills EJ, Kengne AP, Jaffar SS, Clarke A, Moradi T, Ekström AM, Lilford R. Statin use and all-cause mortality in people living with HIV: a systematic review and meta-analysis. BMC Infect Dis 2018; 18:258. [PMID: 29866059 PMCID: PMC5987595 DOI: 10.1186/s12879-018-3162-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 05/23/2018] [Indexed: 01/31/2023] Open
Abstract
Background It is unknown whether statin use among people living with HIV results in a reduction in all-cause mortality. We aimed to evaluate the effect of statin use on all-cause mortality among people living with HIV. Methods We conducted comprehensive literature searches of Medline, Embase, CINAHL, the Cochrane Library, and cross-references up to April 2018. We included randomised, quasi-randomised trials and prospective cohort studies that examined the association between statin use and cardio-protective and mortality outcomes among people living with HIV. Two reviewers independently abstracted the data. Hazard ratios (HRs) were pooled using empirical Bayesian random-effect meta-analysis. A number of sensitivity analyses were conducted. Results We included seven studies with a total of 35,708 participants. The percentage of participants on statins across the studies ranged from 8 to 35%. Where reported, the percentage of participants with hypertension ranged from 14 to 35% and 7 to 10% had been diagnosed with diabetes mellitus. Statin use was associated with a 33% reduction in all-cause mortality (pooled HR = 0.67, 95% Credible Interval 0.39 to 0.96). The probability that statin use conferred a moderate mortality benefit (i.e. decreased risk of mortality of at least 25%, HR ≤ 0.75) was 71.5%. Down-weighting and excluding the lower quality studies resulted in a more conservative estimate of the pooled HR. Conclusion Statin use appears to confer moderate mortality benefits in people living with HIV. Electronic supplementary material The online version of this article (10.1186/s12879-018-3162-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olalekan A Uthman
- Warwick-Centre for Applied Health Research and Delivery (WCAHRD), Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Chidozie Nduka
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Samuel I Watson
- Warwick-Centre for Applied Health Research and Delivery (WCAHRD), Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | | | - Andre P Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Shabbar S Jaffar
- Liverpool School of Tropical Medicine, Dept of International Public Health, Liverpool, UK
| | - Aileen Clarke
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Tahereh Moradi
- Institute of Environmental Medicine, Division of Epidemiology, Karolinska Institutet Stockholm, Stockholm, Sweden
| | - Anna-Mia Ekström
- Department of Public Health (IHCAR), Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Richard Lilford
- Warwick-Centre for Applied Health Research and Delivery (WCAHRD), Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
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17
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Mosepele M, Molefe-Baikai OJ, Grinspoon SK, Triant VA. Benefits and Risks of Statin Therapy in the HIV-Infected Population. Curr Infect Dis Rep 2018; 20:20. [PMID: 29804227 DOI: 10.1007/s11908-018-0628-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW HIV-infected patients face an increased risk for cardiovascular disease (CVD), estimated at 1.5- to 2-fold as compared to HIV-uninfected persons. This review provides a recent (within preceding 5 years) summary of the role of statin therapy and associated role in CVD risk reduction among HIV-infected patients on anti-retroviral therapy. RECENT FINDINGS Statins remain the preferred agents for reducing risk for CVD among HIV-infected populations based on guidance extrapolated from general population (HIV-uninfected) cholesterol treatment guidelines across different settings globally. However, HIV-infected patients are consistently under prescribed statin therapy when compared to their HIV-uninfected counterparts. The most commonly studied statins in clinical care and small randomized and cohort studies have been rosuvastatin and atorvastatin. Both agents are preferred for their potent lipid-lowering effects and their favorable or neutral pleotropic effects on chronic inflammation, renal function, and hepatic steatosis among others. However, growing experience with the newer glucuronidated pitavastatin suggests that this agent has virtually no adverse drug interactions with ART or effects on glucose metabolism-all marked additional benefits when compared with rosuvastatin and atorvastatin while maintaining comparable anti-lipid effects. Pitavastatin is therefore the statin of choice for the ongoing largest trial (6500 participants) to test the benefits of statin therapy among HIV-infected adults. Statins are underutilized in the prevention of CVD in HIV-infected populations based on criteria in established cholesterol guidelines. There is a potential role for statin therapy for HIV-infected patients who do not meet guideline criteria which will be further delineated through ongoing clinical trials.
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Affiliation(s)
- Mosepele Mosepele
- Department of Internal Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana. .,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana. .,Sir Ketumile Masire Teaching Hospital, Faculty of Medicine, University of Botswana, 3rd Floor, Block F, Room F4069, Gaborone, Botswana.
| | | | - Steven K Grinspoon
- Program in Nutritional Metabolism, Harvard Medical School & Massachusetts General Hospital, Boston, MA, USA
| | - Virginia A Triant
- Divisions of Infectious Diseases and General Internal Medicine, Harvard Medical School & Massachusetts General Hospital, Boston, MA, USA
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18
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McGettrick P, Barco EA, Mallon PWG. Ageing with HIV. Healthcare (Basel) 2018; 6:healthcare6010017. [PMID: 29443936 PMCID: PMC5872224 DOI: 10.3390/healthcare6010017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/29/2018] [Accepted: 02/07/2018] [Indexed: 12/13/2022] Open
Abstract
The population of people living with HIV (PLWH) is growing older with an estimated 4 million over the age of 50 years, a figure which has doubled since the introduction of effective antiretroviral therapy (ART) and which is increasing globally. Despite effective ART, PLWH still experience excess morbidity and mortality compared to the general population with increased prevalence of age-related, non-AIDS illnesses (NAI) such as cardiovascular disease, malignancies, cognitive impairment and reduced bone mineral density, which impact disability and everyday functioning. This review will discuss the challenges presented by comorbidities in ageing PLWH and discuss the aetiology and management of age-related illnesses in this vulnerable population.
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Affiliation(s)
- Padraig McGettrick
- HIV Molecular Research Group, UCD School of Medicine, University College Dublin, Dublin, Ireland.
- Mater Misericordae University Hospital, Eccles street, Dublin 7, Ireland.
| | - Elena Alvarez Barco
- HIV Molecular Research Group, UCD School of Medicine, University College Dublin, Dublin, Ireland.
| | - Patrick W G Mallon
- HIV Molecular Research Group, UCD School of Medicine, University College Dublin, Dublin, Ireland.
- Mater Misericordae University Hospital, Eccles street, Dublin 7, Ireland.
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19
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Levy ME, Greenberg AE, Magnus M, Younes N, Castel A, Subramanian T, Binkley J, Taylor R, Rayeed N, Akridge C, Purinton S, Moog R, Naughton J, D'Angelo L, Rakhmanina N, Kharfen M, Wood A, Kumar P, Parenti D, Castel A, Greenberg A, Happ LP, Jaurretche M, Lewis B, Peterson J, Younes N, Wilcox R, Rana S, Horberg M, Fernandez R, Hebou A, Dieffenbach C, Masur H, Bordon J, Teferi G, Benator D, Ruiz ME, Goldstein D, Hardy D. Evaluation of Statin Eligibility, Prescribing Practices, and Therapeutic Responses Using ATP III, ACC/AHA, and NLA Dyslipidemia Treatment Guidelines in a Large Urban Cohort of HIV-Infected Outpatients. AIDS Patient Care STDS 2018; 32:58-69. [PMID: 29561173 PMCID: PMC5808384 DOI: 10.1089/apc.2017.0304] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Statin coverage has been examined among HIV-infected patients using Adult Treatment Panel III (ATP III) and American College of Cardiology/American Heart Association (ACC/AHA) guidelines, although not with newer National Lipid Association (NLA) guidelines. We investigated statin eligibility, prescribing practices, and therapeutic responses using these three guidelines. Sociodemographic, clinical, and laboratory data were collected between 2011 and 2016 for HIV-infected outpatients enrolled in the DC Cohort, a multi-center, prospective, observational study in Washington, DC. This analysis included patients aged ≥21 years receiving primary care at their HIV clinic site with ≥1 cholesterol result available. Of 3312 patients (median age 52; 79% black), 52% were eligible for statins based on ≥1 guideline, including 45% (NLA), 40% (ACC/AHA), and 30% (ATP III). Using each guideline, 49% (NLA), 56% (ACC/AHA), and 73% (ATP III) of eligible patients were prescribed statins. Predictors of new prescriptions included older age (aHR = 1.16 [1.08-1.26]/5 years), body mass index ≥30 (aHR = 1.50 [1.07-2.11]), and diabetes (aHR = 1.35 [1.03-1.79]). Hepatitis C coinfection was inversely associated with statin prescriptions (aHR = 0.67 [0.45-1.00]). Among 216 patients with available cholesterol results pre-/post-prescription, 53% achieved their NLA cholesterol goal after 6 months. Hepatitis C coinfection was positively associated (aHR = 1.87 [1.06-3.32]), and depression (aHR = 0.56 [0.35-0.92]) and protease inhibitor use (aHR = 0.61 [0.40-0.93]) were inversely associated, with NLA goal achievement. Half of patients were eligible for statins based on current US guidelines, with the highest proportion eligible based on NLA guidelines, yet, fewer received prescriptions and achieved treatment goals. Greater compliance with recommended statin prescribing practices may reduce cardiovascular disease risk among HIV-infected individuals.
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Affiliation(s)
- Matthew E. Levy
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Alan E. Greenberg
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Manya Magnus
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Naji Younes
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Amanda Castel
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Thilakavathy Subramanian
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Jeffery Binkley
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Rob Taylor
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Nabil Rayeed
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Cheryl Akridge
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Stacey Purinton
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Ryan Moog
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Jeff Naughton
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Lawrence D'Angelo
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Natella Rakhmanina
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Michael Kharfen
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Angela Wood
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Princy Kumar
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - David Parenti
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Amanda Castel
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Alan Greenberg
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Lindsey Powers Happ
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Maria Jaurretche
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Brittany Lewis
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - James Peterson
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Naji Younes
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Ronald Wilcox
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Sohail Rana
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Michael Horberg
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Ricardo Fernandez
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Annick Hebou
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Carl Dieffenbach
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Henry Masur
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Jose Bordon
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Gebeyehu Teferi
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Debra Benator
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Maria Elena Ruiz
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - Deborah Goldstein
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | - David Hardy
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
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Bedimo R, Abodunde O. Metabolic and Cardiovascular Complications in HIV/HCV-Co-infected Patients. Curr HIV/AIDS Rep 2017; 13:328-339. [PMID: 27595755 DOI: 10.1007/s11904-016-0333-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Fifteen to thirty percent of HIV-infected persons in North America and Europe are co-infected with chronic hepatitis C (HCV). The latter is associated with a significant number of extra-hepatic metabolic complications that could compound HIV-associated increased cardiovascular risk. This article reviews the basic science and epidemiologic and clinical evidence for increased cardio-metabolic risk among HIV/HCV-co-infected patients and discusses potential underlying mechanisms. We will finally review the impact of control of HCV viremia on the cardio-metabolic morbidity and mortality of HIV/HCV-co-infected patients. RECENT FINDINGS HCV infection is associated with a number of immune-related complications such as cryoglobulinemia but also metabolic complications including dyslipidemias, hepatic steatosis, insulin resistance, diabetes, and chronic kidney disease. The incidence of these complications is higher among HIV-co-infected patients and might contribute to increased mortality. The potential mechanisms of increased cardiovascular risk among HIV/HCV-co-infected subjects include endothelial dysfunction, chronic inflammation and immune activation, the cardio-metabolic effects of HCV-induced hepatic steatosis and fibrosis or insulin resistance, and chronic kidney disease. However, epidemiologic studies show discordant findings as to whether HCV co-infection further increases the risk of atherosclerotic cardiovascular diseases (acute myocardial infarctions and strokes) among HIV-infected patients. Nonetheless, successful treatment of HCV is associated with significant improvements in cardio-metabolic risk factors including diabetes mellitus. HCV co-infection is associated with a higher incidence of metabolic complications-and likely increased risk of cardiovascular events-that might contribute to increased mortality in HIV. These appear to improve with successful HCV therapy.
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Affiliation(s)
- Roger Bedimo
- Infectious Diseases Section, Medical Service, Veterans Affairs North Texas Healthcare System, Dallas, TX, USA. .,Department of Internal Medicine, Division of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Oladapo Abodunde
- Infectious Diseases Section, Medical Service, Veterans Affairs North Texas Healthcare System, Dallas, TX, USA.,Department of Internal Medicine, Division of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
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21
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Escota GV, O'Halloran JA, Powderly WG, Presti RM. Understanding mechanisms to promote successful aging in persons living with HIV. Int J Infect Dis 2017; 66:56-64. [PMID: 29154830 DOI: 10.1016/j.ijid.2017.11.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/26/2017] [Accepted: 11/03/2017] [Indexed: 01/05/2023] Open
Abstract
The mortality rate associated with HIV infection plummeted after the introduction of effective antiretroviral therapy pioneered two decades ago. As a result, HIV-infected people now have life expectancies comparable to that of HIV-uninfected individuals. Despite this, increased rates of osteoporosis, chronic liver disease, and in particular cardiovascular disease have been reported among people living with HIV infection. With the aging HIV-infected population, the burden of these comorbid illnesses may continue to accrue over time. In this paper, we present an overview of the aging HIV-infected population, its epidemiology and the many challenges faced. How to define and measure successful aging will also be reviewed. Finally, opportunities that may help mitigate the challenges identified and ensure successful aging among people living with HIV infection will be examined.
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Affiliation(s)
- Gerome V Escota
- Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, MO, USA.
| | - Jane A O'Halloran
- Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, MO, USA
| | - William G Powderly
- Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, MO, USA
| | - Rachel M Presti
- Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, MO, USA
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22
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Drechsler H, Ayers C, Cutrell J, Maalouf N, Tebas P, Bedimo R. Current use of statins reduces risk of HIV rebound on suppressive HAART. PLoS One 2017; 12:e0172175. [PMID: 28249009 PMCID: PMC5331966 DOI: 10.1371/journal.pone.0172175] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/31/2017] [Indexed: 11/18/2022] Open
Abstract
Background Despite compelling evidence for activity against HIV-1 in vitro, a virologic effect of statins has not been shown in clinical studies. Given their short plasma half-lives, such an effect may be transient and only apparent during ongoing exposure. Methods We studied all HIV infected US-Veterans who started HAART 1995–2011, had a documented HIV viral load (VL) >1000 copies/mL, reached an undetectable VL on HAART, and had ≥1 follow-up VL within 13 months. We defined virologic failure (VF) as the first VL >1,000 copies/mL or the first of 2 consecutive VL >200 copies/mL. We built a time-updated drug exposure model for antiretrovirals (ARVs), statins, and other cardiovascular drugs (CVMs), investigating current use (yes/no), recent use (proportion of days used), and categorical use (ever/never). We used both multiply adjusted and inverse-probability-weighted (IPW) Cox models to explore the association between statin and CVM use and VF. Results 19,324 veterans met inclusion criteria. Median follow-up was 13 months (IQR: 5–32 months); 63% experienced VF after a median time of 9 months (IQR 4–21 months). Almost 1/3 patients ever used statins but exposure comprised only 41% of follow-up time covered after initial prescription. Unadjusted, current statin use was associated with a hazard ratio (HR) for VF of 0.60 (CI: 0.56–0.65). This remained statistically significant after multivariate adjustment (MVA) for demographics, HIV and HAART parameters [HR 0.81 (CI: 0.75–0.88), p<0.001] and IPW (truncation <1%/>99%) HR: 0.83 (CI: 0.75–0.92), p<0.001]. No independent association was observed for other CVMs. The association between categorical-statin use and VF after MVA was much weaker: HR 0.94 (CI: 0.88–1.00, p = 0.04). Conclusion Current statin exposure was associated with reduced risk of VF in univariate, multivariate, and inverse-probability-weighted models. Our results highlight the importance of time-updated medication exposure models for observational studies.
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Affiliation(s)
- Henning Drechsler
- Infectious Diseases Section, Medical Service, VA North Texas Health Care System, Dallas, Texas, United States of America
- Division of Infectious Diseases, Department of Medicine, University of Texas Southwestern School of Medicine, Dallas, Texas, United States of America
- * E-mail:
| | - Colby Ayers
- Division of Biostatistics, Department of Clinical Sciences, University of Texas Southwestern School of Medicine, Dallas, Texas, United States of America
| | - James Cutrell
- Infectious Diseases Section, Medical Service, VA North Texas Health Care System, Dallas, Texas, United States of America
- Division of Infectious Diseases, Department of Medicine, University of Texas Southwestern School of Medicine, Dallas, Texas, United States of America
| | - Naim Maalouf
- Infectious Diseases Section, Medical Service, VA North Texas Health Care System, Dallas, Texas, United States of America
- Division of Infectious Diseases, Department of Medicine, University of Texas Southwestern School of Medicine, Dallas, Texas, United States of America
| | - Pablo Tebas
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Roger Bedimo
- Infectious Diseases Section, Medical Service, VA North Texas Health Care System, Dallas, Texas, United States of America
- Division of Infectious Diseases, Department of Medicine, University of Texas Southwestern School of Medicine, Dallas, Texas, United States of America
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Spagnuolo V, Galli L, Poli A, Salpietro S, Gianotti N, Piatti P, Cossarini F, Vinci C, Carini E, Lazzarin A, Castagna A. Associations of statins and antiretroviral drugs with the onset of type 2 diabetes among HIV-1-infected patients. BMC Infect Dis 2017; 17:43. [PMID: 28061820 PMCID: PMC5219726 DOI: 10.1186/s12879-016-2099-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 12/08/2016] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Statin use is associated with a modest increase in the incidence of type 2 diabetes mellitus (DM) among the general population. However, HIV-infected patients have a higher risk of developing DM, and it is unclear whether statins have a diabetogenic effect in these patients. Therefore, we investigated the associations of statin use and exposure to antiretroviral drugs with type 2 DM onset in a cohort of HIV-infected patients. METHODS This retrospective, controlled, cohort study identified HIV-1-infected patients who did not have DM and were not receiving statins at their antiretroviral treatment (ART) initiation. Follow-up was accrued from ART initiation to the earliest instance of a DM diagnosis, loss to follow-up, death, or last available visit. The incidence of DM was estimated according to statin use, which was adjusted for periods without statin treatment. The Fine-Gray competing risk model was used in the multivariate analysis to identify risk factors for developing DM. RESULTS The analyses evaluated 6,195 patients followed for 9.8 years (interquartile range: 4.3-16.3 years). During 64,149 person-years of follow-up (PYFU), 235 patients developed DM (crude incidence: 3.66 [95%CI: 3.20-4.13] per 1,000 PYFU), and 917 (14%) patients used statins. After adjusting for potential confounders, statin use was associated with a non-significant increase in the risk of DM (AHR: 1.21, 95% CI: 0.71-2.07; P = 0.47). DM was more likely among patients who were ever treated with stavudine, and less likely among those ever treated using emtricitabine, tenofovir, abacavir, efavirenz, nevirapine, atazanavir or darunavir. CONCLUSIONS A higher risk of diabetes mellitus was not associated with statin treatment but with traditional risk factors and stavudine use while a reduced risk of DM was associated with the use of emtricitabine, tenofovir, abacavir, efavirenz, nevirapine, atazanavir or darunavir.
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Affiliation(s)
- Vincenzo Spagnuolo
- Department of Infectious Diseases, San Raffaele Scientific Institute, via Stamira d’Ancona 20, 20127 Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Laura Galli
- Department of Infectious Diseases, San Raffaele Scientific Institute, via Stamira d’Ancona 20, 20127 Milan, Italy
| | - Andrea Poli
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Stefania Salpietro
- Department of Infectious Diseases, San Raffaele Scientific Institute, via Stamira d’Ancona 20, 20127 Milan, Italy
| | - Nicola Gianotti
- Department of Infectious Diseases, San Raffaele Scientific Institute, via Stamira d’Ancona 20, 20127 Milan, Italy
| | - Piermarco Piatti
- Cardiometabolic and Clinical Trials Unit, Internal Medicine Department, Metabolic and Cardiovascular Division, San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Cossarini
- Department of Infectious Diseases, San Raffaele Scientific Institute, via Stamira d’Ancona 20, 20127 Milan, Italy
| | - Concetta Vinci
- Department of Infectious Diseases, San Raffaele Scientific Institute, via Stamira d’Ancona 20, 20127 Milan, Italy
| | - Elisabetta Carini
- Department of Infectious Diseases, San Raffaele Scientific Institute, via Stamira d’Ancona 20, 20127 Milan, Italy
| | - Adriano Lazzarin
- Department of Infectious Diseases, San Raffaele Scientific Institute, via Stamira d’Ancona 20, 20127 Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Antonella Castagna
- Department of Infectious Diseases, San Raffaele Scientific Institute, via Stamira d’Ancona 20, 20127 Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
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Abstract
PURPOSE OF REVIEW To review the newest research about the effects of combination antiretroviral therapy (cART) on cancer risk. RECENT FINDINGS HIV+ persons are at increased risk of cancer. As this risk is higher for malignancies driven by viral and bacterial coinfections, classifying malignancies into infection-related and infection-unrelated has been an emerging trend. Cohorts have detected major reductions in the incidence of Kaposi sarcoma and non-Hodgkin lymphoma (NHL) following cART initiation among immunosuppressed HIV+ persons. However, recent randomized data indicate that cART reduces risk of Kaposi sarcoma and NHL also during early HIV infection before overt immunosuppression occurs. Long-term effects of cART exposure on cancer risk are not well defined; according to basic and epidemiological research, there might be specific associations of each cART class with distinct patterns of cancer risk. SUMMARY The relationship between cART exposure and cancer risk is complex and nuanced. It is an intriguing fact that, whether initiated during severe immunosuppression or not, cART reduces risk of Kaposi sarcoma and NHL. Further research should identify mediators of the benefit of immediate cART initiation in reducing cancer risk, understand the relationship between long-term cART exposure and cancer incidence and assess whether adjuvant anti-inflammatory therapies can reduce cancer risk during treated HIV infection.
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Affiliation(s)
- Álvaro H Borges
- Centre for Health and Infectious Diseases Research, Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Abstract
PURPOSE OF REVIEW To evaluate evidence that statins reduce cardiovascular risk in patients living with HIV. RECENT FINDINGS Moderate to high-dose atorvastatin and rosuvastatin appear to reduce noncalcified coronary plaque volume and slow progression of carotid intima-media thickness in patients with treated HIV infection. Expected lipoprotein changes with statins on the background of modern antiretroviral therapy are similar to the general population. In addition to lipids, the statin benefit may be mediated in part by improvements in vascular inflammation and levels of T-cell and monocyte activation. One concern is the potential for rosuvastatin to cause insulin resistance. Decisions to prescribe statins must be done in the context of global risk assessment, but traditional risk calculators such as the Framingham Risk Score or the American College of Cardiology/American Heart Association pooled-risk equations underestimate risk in this population. Furthermore, many patients with subclinical disease would not be recommended for statins according to the most recent American College of Cardiology/American Heart Association guidelines. SUMMARY Statins are likely to improve cardiovascular outcomes for patients with HIV, but results of the first outcome study are not expected until 2020. In the meantime, clinicians should individualize statin prescriptions, and should consider using more potent statins (rosuvastatin, atorvastatin, and pitavastatin) when possible.
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Nou E, Lo J, Hadigan C, Grinspoon SK. Pathophysiology and management of cardiovascular disease in patients with HIV. Lancet Diabetes Endocrinol 2016; 4:598-610. [PMID: 26873066 PMCID: PMC4921313 DOI: 10.1016/s2213-8587(15)00388-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/05/2015] [Accepted: 10/07/2015] [Indexed: 12/15/2022]
Abstract
Results from several studies have suggested that people with HIV have an increased risk of cardiovascular disease, especially coronary heart disease, compared with people not infected with HIV. People living with HIV have an increased prevalence of traditional cardiovascular disease risk factors, and HIV-specific mechanisms such as immune activation. Although older, more metabolically harmful antiretroviral regimens probably contributed to the risk of cardiovascular disease, new data suggest that early and continuous use of modern regimens, which might have fewer metabolic effects, minimises the risk of myocardial infarction by maintaining viral suppression and decreasing immune activation. Even with antiretroviral therapy, however, immune activation persists in people with HIV and could contribute to accelerated atherosclerosis, especially of coronary lesions that are susceptible to rupture. Therefore, treatments that safely reduce inflammation in people with HIV could provide additional cardiovascular protection alongside treatment of both traditional and non-traditional risk factors.
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Affiliation(s)
- Eric Nou
- Program in Nutritional Metabolism, Massachusetts General Hospital, Boston, MA, USA
| | - Janet Lo
- Program in Nutritional Metabolism, Massachusetts General Hospital, Boston, MA, USA
| | - Colleen Hadigan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Steven K Grinspoon
- Program in Nutritional Metabolism, Massachusetts General Hospital, Boston, MA, USA.
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Abstract
HIV-infected individuals are at an increased risk of cardiovascular disease (CVD) and other HIV-related co-morbidities. This is due in part to dyslipidemia associated with antiretroviral therapy and increased inflammation and immune activation from chronic HIV infection. Statins not only have potent lipid-lowering properties but are also anti-inflammatory and immunomodulators. Studies suggest that statin therapy in the HIV-infected population may decrease the risk of CVD and other non-AIDS-defining co-morbidities. This review summarizes the recent literature on statin use in the HIV setting.
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Affiliation(s)
- Allison Ross Eckard
- Departments of Pediatrics and Medicine, Divisions of Infectious Diseases, Medical University of South Carolina, 135 Rutledge Ave, MSC 752, Charleston, SC, 29425, USA,
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d’Ettorre G, Ceccarelli G, Pavone P, Vittozzi P, De Girolamo G, Schietroma I, Serafino S, Giustini N, Vullo V. What happens to cardiovascular system behind the undetectable level of HIV viremia? AIDS Res Ther 2016; 13:21. [PMID: 27127532 PMCID: PMC4848790 DOI: 10.1186/s12981-016-0105-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 04/14/2016] [Indexed: 11/08/2022] Open
Abstract
Despite the combined antiretroviral therapy has improved the length and quality of life of HIV infected patients, the survival of these patients is always decreased compared with the general population. This is the consequence of non-infectious illnesses including cardio vascular diseases. In fact large studies have indicated an increased risk of coronary atherosclerotic disease, myocardial infarction even in HIV patients on cART. In HIV infected patients several factors may contribute to the pathogenesis of cardiovascular problems: life-style, metabolic parameters, genetic predisposition, viral factors, immune activation, chronic inflammation and side effects of antiretroviral therapy. The same factors may also contribute to complicate the clinical management of these patients. Therefore, treatment of these non-infectious illnesses in HIV infected population is an emerging challenge for physicians. The purpose of this review is to focus on the new insights in non AIDS-related cardiovascular diseases in patients with suppressed HIV viremia.
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Abstract
OBJECTIVE Antigen persistence due to HIV is a major source of inflammation and substantial immune activation, both of which are linked to accelerated aging. This illustrates the need to reduce immune activation in these patients and subsequently decrease the risk of cardiovascular diseases and other non-AIDS-defining comorbidities. METHODS CD4 T cells were infected with HIV-1 isolates in the presence or absence of atorvastatin (0.25 to 1 μg/ml) for 24-48 h. Atorvastatin-induced anti-inflammatory functions and anti-viral replication were measured in vitro. RESULTS Atorvastatin, a lipid-lowering medication, exerted a broad spectrum of anti-inflammatory functions by reducing T-cell immune activation markers (e.g. CD38, HLA-DR and Ki67), lowering HIV-1 co-receptor CCR-5, and decreasing proliferative capabilities of CD4 T cells in vitro. In contrast, atorvastatin expanded regulatory T cells (Tregs) and upregulated the expression of T-cell immunoglobulin and ITIM domain (TIGIT), which enhanced the suppressive activity of Tregs. Furthermore, atorvastatin upregulated the cyclin-dependent kinase inhibitor p21, which is also known as cip-1 and waf-1, in the CD4 T cells. Upregulation of p21 in CD4 T cells rendered them less susceptible to HIV-1 infection and replication whereas siRNA-mediated p21 depletion and/or p21 selective inhibitor rescued viral replication. Interestingly, atorvastatin reduced HIV infection in both rested and phytohemagglutinin-activated CD4 T cells in vitro. Finally, atorvastatin mediated p21 upregulation occurred via mevalonate pathway, but independent of p53. CONCLUSION The results demonstrate a novel mechanism by which atorvastatin induced resistance of CD4 T cells to HIV-1 infection via p21 upregulation and suggest that statins may hold particular promise for some HIV-infected individuals.
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Schnitzer ME, Lok JJ, Bosch RJ. Double robust and efficient estimation of a prognostic model for events in the presence of dependent censoring. Biostatistics 2016; 17:165-77. [PMID: 26224070 PMCID: PMC4679073 DOI: 10.1093/biostatistics/kxv028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 07/01/2015] [Accepted: 07/03/2015] [Indexed: 01/19/2023] Open
Abstract
In longitudinal data arising from observational or experimental studies, dependent subject drop-out is a common occurrence. If the goal is estimation of the parameters of a marginal complete-data model for the outcome, biased inference will result from fitting the model of interest with only uncensored subjects. For example, investigators are interested in estimating a prognostic model for clinical events in HIV-positive patients, under the counterfactual scenario in which everyone remained on ART (when in reality, only a subset had). Inverse probability of censoring weighting (IPCW) is a popular method that relies on correct estimation of the probability of censoring to produce consistent estimation, but is an inefficient estimator in its standard form. We introduce sequentially augmented regression (SAR), an adaptation of the Bang and Robins (2005. Doubly robust estimation in missing data and causal inference models. Biometrics 61, 962-972.) method to estimate a complete-data prediction model, adjusting for longitudinal missing at random censoring. In addition, we propose a closely related non-parametric approach using targeted maximum likelihood estimation (TMLE; van der Laan and Rubin, 2006. Targeted maximum likelihood learning. The International Journal of Biostatistics 2 (1), Article 11). We compare IPCW, SAR, and TMLE (implemented parametrically and with Super Learner) through simulation and the above-mentioned case study.
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Affiliation(s)
| | - Judith J Lok
- The Department of Biostatistics and the Center for Biostatistics in AIDS Research at Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Ronald J Bosch
- The Department of Biostatistics and the Center for Biostatistics in AIDS Research at Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
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31
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Jacobson TA, Maki KC, Orringer CE, Jones PH, Kris-Etherton P, Sikand G, La Forge R, Daniels SR, Wilson DP, Morris PB, Wild RA, Grundy SM, Daviglus M, Ferdinand KC, Vijayaraghavan K, Deedwania PC, Aberg JA, Liao KP, McKenney JM, Ross JL, Braun LT, Ito MK, Bays HE, Brown WV. National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 2. J Clin Lipidol 2015; 9:S1-122.e1. [DOI: 10.1016/j.jacl.2015.09.002] [Citation(s) in RCA: 315] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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32
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Silverberg MJ, Lau B, Achenbach CJ, Jing Y, Althoff KN, D’Souza G, Engels EA, Hessol N, Brooks JT, Burchell AN, Gill MJ, Goedert JJ, Hogg R, Horberg MA, Kirk GD, Kitahata MM, Korthuis PT, Mathews WC, Mayor A, Modur SP, Napravnik S, Novak RM, Patel P, Rachlis AR, Sterling TR, Willig JH, Justice AC, Moore RD, Dubrow R. Cumulative Incidence of Cancer Among Persons With HIV in North America: A Cohort Study. Ann Intern Med 2015; 163:507-18. [PMID: 26436616 PMCID: PMC4711936 DOI: 10.7326/m14-2768] [Citation(s) in RCA: 226] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Cancer is increasingly common among persons with HIV. OBJECTIVE To examine calendar trends in cumulative cancer incidence and hazard rate by HIV status. DESIGN Cohort study. SETTING North American AIDS Cohort Collaboration on Research and Design during 1996 to 2009. PARTICIPANTS 86 620 persons with HIV and 196 987 uninfected adults. MEASUREMENTS Cancer type-specific cumulative incidence by age 75 years and calendar trends in cumulative incidence and hazard rates, each by HIV status. RESULTS Cumulative incidences of cancer by age 75 years for persons with and without HIV, respectively, were as follows: Kaposi sarcoma, 4.4% and 0.01%; non-Hodgkin lymphoma, 4.5% and 0.7%; lung cancer, 3.4% and 2.8%; anal cancer, 1.5% and 0.05%; colorectal cancer, 1.0% and 1.5%; liver cancer, 1.1% and 0.4%; Hodgkin lymphoma, 0.9% and 0.09%; melanoma, 0.5% and 0.6%; and oral cavity/pharyngeal cancer, 0.8% and 0.8%. Among persons with HIV, calendar trends in cumulative incidence and hazard rate decreased for Kaposi sarcoma and non-Hodgkin lymphoma. For anal, colorectal, and liver cancer, increasing cumulative incidence, but not hazard rate trends, were due to the decreasing mortality rate trend (-9% per year), allowing greater opportunity to be diagnosed. Despite decreasing hazard rate trends for lung cancer, Hodgkin lymphoma, and melanoma, cumulative incidence trends were not seen because of the compensating effect of the declining mortality rate. LIMITATION Secular trends in screening, smoking, and viral co-infections were not evaluated. CONCLUSION Cumulative cancer incidence by age 75 years, approximating lifetime risk in persons with HIV, may have clinical utility in this population. The high cumulative incidences by age 75 years for Kaposi sarcoma, non-Hodgkin lymphoma, and lung cancer support early and sustained antiretroviral therapy and smoking cessation.
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Affiliation(s)
| | - Bryan Lau
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Chad J. Achenbach
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Center for Global Health and Lurie Cancer Center, Chicago, IL, USA
| | - Yuezhou Jing
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gypsyamber D’Souza
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Eric A. Engels
- National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Nancy Hessol
- Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
| | - John T. Brooks
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ann N. Burchell
- Ontario HIV Treatment Network and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - M. John Gill
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - James J. Goedert
- National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Robert Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada; Faculty of Health Sciences, Simon Fraser, Burnaby, Canada
| | - Michael A. Horberg
- HIV/AIDS, Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, MD, USA
| | - Gregory D. Kirk
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mari M. Kitahata
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Phillip T. Korthuis
- Department of Medicine, Oregon Health and Sciences University, Portland, OR, USA
| | - William C. Mathews
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Angel Mayor
- Retrovirus Research Center, Universidad Central del Caribe School of Medicine, Bayamón, Puerto Rico
| | - Sharada P. Modur
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sonia Napravnik
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Richard M. Novak
- College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Pragna Patel
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Anita R. Rachlis
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | | | - James H. Willig
- Division of Infectious Diseases, University of Alabama, Birmingham, AL, USA
| | - Amy C. Justice
- VA Connecticut Healthcare System and Yale University Schools of Medicine and Public Health, New Haven, CT, USA
| | - Richard D. Moore
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Robert Dubrow
- VA Connecticut Healthcare System and Yale University Schools of Medicine and Public Health, New Haven, CT, USA
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Lang S, Lacombe JM, Mary-Krause M, Partisani M, Bidegain F, Cotte L, Aslangul E, Chéret A, Boccara F, Meynard JL, Pradier C, Roger PM, Tattevin P, Costagliola D, Molina JM. Is Impact of Statin Therapy on All-Cause Mortality Different in HIV-Infected Individuals Compared to General Population? Results from the FHDH-ANRS CO4 Cohort. PLoS One 2015. [PMID: 26200661 PMCID: PMC4511794 DOI: 10.1371/journal.pone.0133358] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The effect of statins on all-cause mortality in the general population has been estimated as 0.86 (95%CI 0.79-0.94) for primary prevention. Reported values in HIV-infected individuals have been discordant. We assessed the impact of statin-based primary prevention on all-cause mortality among HIV-infected individuals. METHODS Patients were selected among controls from a multicentre nested case-control study on the risk of myocardial infarction. Patients with prior cardiovascular or cerebrovascular disorders were not eligible. Potential confounders, including variables that were associated either with statin use and/or death occurrence and statin use were evaluated within the last 3 months prior to inclusion in the case-control study. Using an intention to continue approach, multiple imputation of missing data, Cox's proportional hazard models or propensity based weighting, the impact of statins on the 7-year all-cause mortality was evaluated. RESULTS Among 1,776 HIV-infected individuals, 138 (8%) were statins users. During a median follow-up of 53 months, 76 deaths occurred, including 6 in statin users. Statin users had more cardiovascular risk factors and a lower CD4 T cell nadir than statin non-users. In univariable analysis, the death rate was higher in statins users (11% vs 7%, HR 1.22, 95%CI 0.53-2.82). The confounders accounted for were age, HIV transmission group, current CD4 T cell count, haemoglobin level, body mass index, smoking status, anti-HCV antibodies positivity, HBs antigen positivity, diabetes and hypertension. In the Cox multivariable model the estimated hazard ratio of statin on all-cause mortality was estimated as 0.86 (95%CI 0.34-2.19) and it was 0.83 (95%CI 0.51-1.35) using inverse probability treatment weights. CONCLUSION The impact of statin for primary prevention appears similar in HIV-infected individuals and in the general population.
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Affiliation(s)
- Sylvie Lang
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique (IPLESP UMRS 1136), F75013, Paris, France
- * E-mail:
| | - Jean-Marc Lacombe
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique (IPLESP UMRS 1136), F75013, Paris, France
| | - Murielle Mary-Krause
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique (IPLESP UMRS 1136), F75013, Paris, France
| | - Marialuisa Partisani
- Hôpitaux Universitaires de Strasbourg, Le Trait D’Union, centre de soins de l’infection par le VIH, Strasbourg, France
| | - Frédéric Bidegain
- APHP, Hôpital Avicenne, service de maladie infectieuse, Bobigny, France
| | - Laurent Cotte
- Hospices Civils de Lyon, Hôpital de la Croix Rousse, service des maladies infectieuses et tropicales, Lyon, France
- INSERM U1052, Lyon, France
| | - Elisabeth Aslangul
- APHP, Hôtel Dieu, service de médecine interne, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Antoine Chéret
- APHP, Hôtel Necker, laboratoire de virologie, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, EA 3620, Paris, France
- Centre hospitalier de Tourcoing, service des maladies infectieuses, Tourcoing, France
| | - Franck Boccara
- APHP, Hôpital Saint-Antoine, service de cardiologie, Paris, France
- Sorbonne Universités, UPMC Univ Paris 06, INSERM (UMRS 938), F75012, Paris, France
| | - Jean-Luc Meynard
- APHP, Hôpital Saint-Antoine, service des maladies infectieuses et tropicales, Paris, France
| | - Christian Pradier
- Centre hospitalier universitaire de Nice, groupe hospitalier l’Archet, service de santé publique, Nice, France
| | - Pierre-Marie Roger
- Centre hospitalier universitaire de Nice, groupe hospitalier l’Archet, service d’infectiologie, Nice, France
- Université de Nice, Sophia-Antipolis, France
| | - Pierre Tattevin
- Hôpital Universitaire Pontchaillou, service des maladies infectieuses et USI, Rennes, France
| | - Dominique Costagliola
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique (IPLESP UMRS 1136), F75013, Paris, France
| | - Jean-Michel Molina
- APHP, Hôpital Saint-Louis, service des maladies infectieuses et tropicales, Paris, France
- Université de Paris Diderot Paris 7, Sorbonne Paris Cité, INSERM (U941), Paris, France
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Erlandson KM, Jiang Y, Debanne SM, McComsey GA. Rosuvastatin Worsens Insulin Resistance in HIV-Infected Adults on Antiretroviral Therapy. Clin Infect Dis 2015; 61:1566-72. [PMID: 26157049 DOI: 10.1093/cid/civ554] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 06/29/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Statins are associated with increased diabetes risk in large, human immunodeficiency virus (HIV)-uninfected cohorts; the impact of statins on insulin resistance or diabetes in HIV-infected persons has not been assessed within a randomized controlled study. METHODS HIV-infected participants on stable antiretroviral therapy with a low-density lipoprotein cholesterol level of ≤130 mg/dL and heightened immune activation or inflammation were randomized to rosuvastatin 10 mg daily or placebo for 96 weeks. Fasting serum glucose, insulin, and hemoglobin A1C (HgbA1C) were measured; insulin resistance was estimated by calculating the homeostatic model assessment of insulin resistance (HOMA-IR); and a 2-hour oral glucose tolerance test was administered. RESULTS Seventy-two participants were randomized to rosuvastatin therapy and 75 to placebo. Increases in fasting glucose were observed within both groups but were not different between study arms (P = .115); changes in glucose tolerance and HgbA1C did not differ between study arms (P = .920 and P = .650, respectively). Criteria for diabetes were met by 1 participant in the rosuvastatin and 3 in the placebo arm by week 96. Compared with placebo, rosuvastatin therapy was associated with significantly greater increases in insulin and HOMA-IR (P = .008 and P = .004, respectively). CONCLUSIONS We detected a significant worsening in insulin resistance and an increase in the proportion of participants with impaired fasting glucose but not a clinical diagnosis of diabetes in the rosuvastatin arm. Our findings suggest that prescription of statin therapy should be accompanied by a careful consideration of the risks and benefits, particularly in patients with lower cardiovascular disease risk. CLINICAL TRIALS REGISTRATION NCT01218802.
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Affiliation(s)
- Kristine M Erlandson
- Department of Medicine, Divisions of Infectious Diseases and Geriatric Medicine, University of Colorado, Aurora
| | - Ying Jiang
- Department of Epidemiology and Biostatistics
| | | | - Grace A McComsey
- Department of Medicine and Pediatrics, Division of Pediatric Infectious Diseases and Rheumatology, Case Western Reserve University, Cleveland, Ohio
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Krsak M, Kent DM, Terrin N, Holcroft C, Skinner SC, Wanke C. Myocardial Infarction, Stroke, and Mortality in cART-Treated HIV Patients on Statins. AIDS Patient Care STDS 2015; 29:307-13. [PMID: 25855882 DOI: 10.1089/apc.2014.0309] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Despite combination antiretroviral therapy (cART), people living with HIV (PLWH) continue to have more systemic inflammation and metabolic disturbances than the general population. These risk factors for atherosclerosis and organ dysfunction may be ameliorated by statins. We retrospectively analyzed 438 cART treated PLWH from the Nutrition For Healthy Living (NFHL) cohort to determine the association between statins and myocardial infarction (MI), stroke, and all-cause mortality as a composite. We used Cox proportional hazards regression as our main analysis. The average age was 44 years, 32% were women, and 67 of the 438 subjects used statins. There was no association between statins and our composite endpoint in two separate models [1.26 (0.57-2.79) in statin history model and 0.93 (0.65-1.32) per year in statin duration model]. The composite outcome was significantly associated with CD4 count, age, and smoking status in both models. CD4 count remained significant even after exclusion of mortality from the composite (HR=0.88, p=0.02). Confounding control via propensity scoring and multiple imputations did not change the results. Statins did not have an effect on MI, stroke, and mortality. Interestingly, CD4 count appears to be an important predictor of these outcomes, even after exclusion of death from the composite.
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Affiliation(s)
- Martin Krsak
- Tufts Medical Center and Tufts University, Boston, Massachusetts
| | - David M. Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Tufts Medical Center, Boston, Massachusetts
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Norma Terrin
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | | | - Sally C. Skinner
- Tufts Medical Center and Tufts University, Boston, Massachusetts
| | - Christine Wanke
- Tufts Medical Center and Tufts University, Boston, Massachusetts
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Abstract
INTRODUCTION After the introduction of highly active antiretroviral treatment, the course of HIV infection turned into a chronic disease and most of HIV-positive patients will soon be over 50 years old. MATERIAL AND METHODS This paper reviews the multiple aspects that physicians have to face while taking care of HIV-positive ageing patients including the definitions of frailty and the prevalence and risk factors of concomitant diseases. From a therapeutic point of view pharmacokinetic changes and antiretroviral-specific toxicities associated with ageing are discussed; finally therapeutic approaches to frailty are reviewed both in HIV-positive and negative patients. CONCLUSION AND DISCUSSION We conclude by suggesting that the combined use of drugs with the least toxicity potential and the promotion of healthy behaviours (including appropriate nutrition and exercise) might be the best practice for ageing HIV-positive subjects.
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Pharmacokinetic Drug–Drug Interaction Study Between Raltegravir and Atorvastatin 20 mg in Healthy Volunteers. J Acquir Immune Defic Syndr 2015; 69:44-51. [DOI: 10.1097/qai.0000000000000544] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Is statin preventing cancer in HIV-1 infected individuals? An inappropriate methodology is a more likely explanation: authors' reply. AIDS 2015; 29:857-9. [PMID: 25985407 DOI: 10.1097/qad.0000000000000585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Warriner AH, Burkholder GA, Overton ET. HIV-related metabolic comorbidities in the current ART era. Infect Dis Clin North Am 2015; 28:457-76. [PMID: 25151566 DOI: 10.1016/j.idc.2014.05.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Despite effective antiretroviral therapy (ART), HIV-infected individuals have residual chronic immune activation that contributes to the pathogenesis of HIV infection. This immune system dysregulation is a pathogenic state manifested by very low naïve T-cell numbers and increased terminally differentiated effector cells that generate excessive proinflammatory cytokines with limited functionality. Immune exhaustion leaves an individual at risk for accelerated aging-related diseases, including renal dysfunction, atherosclerosis, diabetes mellitus, and osteoporosis. We highlight research that clarifies the role of HIV, ART, and other factors that contribute to the development of these diseases among HIV-infected persons.
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Affiliation(s)
- Amy H Warriner
- Department of Medicine, University of Alabama at Birmingham School of Medicine, 908 20th Street South, CCB Room 330A, Birmingham, AL 35294, USA
| | - Greer A Burkholder
- Department of Medicine, University of Alabama at Birmingham School of Medicine, 908 20th Street South, CCB Room 330A, Birmingham, AL 35294, USA
| | - Edgar Turner Overton
- Department of Medicine, University of Alabama at Birmingham School of Medicine, 908 20th Street South, CCB Room 330A, Birmingham, AL 35294, USA.
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Abstract
HIV infection is related to an increased risk of cancer compared with general population, both AIDS-defining cancers (Kaposi's sarcoma, non Hodgkin's lymphoma, invasive cervical cancer) and non-AIDS-defining cancers. Although the advent of the highly active antiretroviral therapy era has decreased the Kaposi's sarcoma and non-Hodgkin's lymphoma incidences, non-AIDS-defining malignancies, such as lung cancer, hepatocarcinoma, anal cancer and skin cancers, remain a major cause of morbidity and death in the HIV-infected population. The clinical presentation is often different between the infected and non-infected populations, often with a more advanced stage at diagnosis, a more aggressive pathology, and associated morbidities like immunosuppression, leading to poorer outcomes. Numerous studies have focused on HIV-related malignancies' treatment, however specific guidelines are still missing. Practitioners have to be careful with interactions between antiretroviral and antineoplastic drugs, particularly through the cytochrome P 450. Because of this, a national multidisciplinary approach, "Cancer and HIV, " was started in 2013 thanks to the National Institute of Cancer (INCa). The aim of this review is to present a scientific update about AIDS-and non-AIDS-defining malignancies, both in their clinical aspects and regarding their specific therapeutic management.
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Abstract
PURPOSE OF REVIEW It is now widely accepted that HIV-infected individuals remain at a higher risk for mortality and age-related morbidities than the general population, but several unresolved issues need to be addressed by the research community in the coming years to further improve the health of HIV-infected individuals in the modern treatment era. RECENT FINDINGS Although recent studies have helped to better define the contribution of HIV to life expectancy and morbidity in the modern antiretroviral therapy (ART) era, questions remain about the generalizability of these findings to a future HIV-infected population that is expected to be much older. Furthermore, although a consensus has emerged that the persistent inflammatory state contributes to morbidity and mortality in this setting, the relative contributions of this process, health-related behaviours, comorbidities and medication toxicities remain incompletely understood. Lastly, significant uncertainty remains over the root causes of the persistent inflammatory state, the specific immunologic pathways to target with interventions and the most appropriate biomarkers to use for surrogate outcomes in pilot trials of immune-based interventions. SUMMARY Each of these issues will be addressed in this review, highlighting recently published and presented studies that inform the discussion, and recommendations will be made for prioritizing the future research agenda.
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Effects of randomized rosuvastatin compared with placebo on bone and body composition among HIV-infected adults. AIDS 2015; 29:175-82. [PMID: 25396266 DOI: 10.1097/qad.0000000000000526] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Statins have a beneficial effect on bone mineral density (BMD) and lean mass in some studies of HIV-uninfected adults; however, this has never been investigated in the setting of HIV infection. DESIGN HIV-infected individuals on stable antiretroviral therapy with a low-density lipoprotein cholesterol level of 130 mg/dl or less and evidence of heightened immune activation or inflammation were randomized to rosuvastatin 10 mg daily or placebo for 96 weeks. METHODS This was a prespecified interim analysis at 48 weeks. Between-group and within-group differences were compared; multivariable regression models were constructed. RESULTS Seventy-two individuals were randomized to statin therapy and 75 to placebo. Modest 48-week relative increases in trochanter BMD [0.9%; 95% confidence interval (95% CI) -0.9 to 0.6] and total hip BMD (0.6%; 95% CI 0.0-1.1) in the statin arm were significantly greater than placebo (P < 0.05). The relationship between statin use and total hip BMD change was robust to adjustment of age, sex, race and smoking status (P = 0.02) and strengthened by inclusion of baseline (P = 0.01) and week 48 change in soluble tumour necrosis factor-α receptor (sTNFR)-1 (P = 0.009). Relative increases in total body, trunk and limb fat were similar between statin and placebo arms (P ≥ 0.58). Although a significant gain in leg lean mass was seen in the statin arm, this was not significantly different compared with placebo (P = 0.36). CONCLUSION The improvements seen in total hip BMD after 48 weeks of rosuvastatin therapy support further potential benefits of statin therapy in HIV, beyond a reduction of cardiovascular risk.
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Overton ET, Sterrett S, Westfall AO, Kahan SM, Burkholder G, Zajac AJ, Goepfert PA, Bansal A. Effects of atorvastatin and pravastatin on immune activation and T-cell function in antiretroviral therapy-suppressed HIV-1-infected patients. AIDS 2014; 28:2627-2631. [PMID: 25574964 PMCID: PMC4338916 DOI: 10.1097/qad.0000000000000475] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This retrospective study was designed to assess statin effects on T-cell activation from HIV-infected individuals. Peripheral blood mononuclear cells from antiretroviral therapy suppressed HIV-infected individuals receiving atorvastatin or pravastatin were evaluated for T-cell activation, exhaustion and function. Atorvastatin was associated with a significant reduction in CD8 T-cell activation (HLA-DR, CD38/HLA-DR) and exhaustion (TIM-3, TIM-3/PD-1) whereas pravastatin had no effect. In contrast, pravastatin increased antigen specific interferon γ production. These results suggest a differential effect of statins on immune activation and function.
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Affiliation(s)
- Edgar Turner Overton
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35294 USA
| | - Sarah Sterrett
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35294 USA
| | - Andrew O. Westfall
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35294 USA
| | - Shannon M. Kahan
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, 35294 USA
| | - Greer Burkholder
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35294 USA
| | - Allan J. Zajac
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, 35294 USA
| | - Paul A. Goepfert
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35294 USA
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, 35294 USA
| | - Anju Bansal
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35294 USA
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Use of statins and risk of AIDS-defining and non-AIDS-defining malignancies among HIV-1 infected patients on antiretroviral therapy. AIDS 2014; 28:2407-15. [PMID: 25160933 DOI: 10.1097/qad.0000000000000443] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Previous studies have shown that statins use is associated with a lower mortality risk or occurrence of non-Hodgkin's lymphoma or non-AIDS-defining malignancies (NADMs) in HIV-positive patients. We evaluated the effect of statin therapy on the occurrence of all AIDS-defining malignancy (ADM) and NADM among HIV-positive patients. DESIGN A chart study on HIV-1 infected patients attending the Infectious Diseases Department of the San Raffaele Scientific Institute, Italy. METHODS Incident malignancies diagnosed since antiretroviral treatment (ART) initiation until October 2012 among treated patients not taking statins at ART initiation. Statin therapy had to precede cancer diagnosis, if it occurred. Malignancies that occurred before ART or statin initiation were excluded. Follow-up was calculated since ART initiation until the first cancer diagnosis or loss to follow-up or death or last available visit, whichever occurred first. Results are described as median (interquartile range, IQR). RESULTS Five thousand, three hundred and fifty-seven HIV-1 treated patients were included. During 52 663 person-years, 740 (14%) patients had a history of statin use; 375 malignancies occurred: 12 (1.6%) malignancies (0 ADM; 12 NADM, crude incidence rate, 1.3/1000 person-years) among statin users and 363 (7.9%) malignancies (194 ADM; 169 NADM, crude incidence rate, 8.4/1000 person-years) among non-statin users. By multivariate Fine-Gray regression, statin use was associated with a lower risk of cancer [adjusted hazard ratio (95% confidence interval) for ever use: 0.45 (0.17-0.71)]. CONCLUSION Among HIV-1 treated patients, statin use was associated with a lower risk of cancer; the benefit was mainly related to AIDS-defining malignancies. Confirmatory studies are needed to consider the residual confounding likely present in this study.
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Cardiovascular disease associated with the human immunodeficiency virus: an update. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:346. [PMID: 25193559 DOI: 10.1007/s11936-014-0346-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OPINION STATEMENT With the advent of increasingly available antiretroviral therapy (ART), the life expectancy of HIV-infected persons is increasing. As they age, HIV-infected persons have increased propensity to typical diseases of aging including cardiovascular disease and accelerated atherosclerosis. The pathogenesis of HIV-associated atherosclerosis is complex and involves a state of chronic inflammation, exposure to traditional risk factors, and metabolic side effects of ART. Treatment of HIV-associated atherosclerosis should include special attention to drug-drug interactions and is best accomplished by a multidisciplinary team experienced in the care of HIV-infected persons.
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Factors contributing to risk for cancer among HIV-infected individuals, and evidence that earlier combination antiretroviral therapy will alter this risk. Curr Opin HIV AIDS 2014; 9:34-40. [PMID: 24225382 DOI: 10.1097/coh.0000000000000025] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW To critically appraise recent published literature about factors associated with cancer risk likely to be influenced by combination antiretroviral therapy (cART) in HIV-infected individuals, and the potential of earlier cART initiation to reduce this risk. RECENT FINDINGS Factors leading to increased risk of non-AIDS-defining malignancies (NADMs) in particular remain poorly understood. Immunodeficiency appears to be key, whereas evidence is emerging that a direct pro-oncogenic effect of HIV, activated inflammatory and coagulation pathways, and cART toxicity may also contribute. By reducing HIV replication, improving immune function, and limiting chronic inflammation, cART initiation at higher CD4 cell counts may, therefore, reduce NADM risk. However, cART only partly normalizes enhanced inflammation and coagulation seen during HIV infection and conflicting laboratory and epidemiological data have been reported as to whether (and how) cART affects NADM risk. Furthermore, secondary analyses of randomized controlled trials comparing early versus delayed cART initiation were inconclusive. SUMMARY Continuous epidemiological surveillance is warranted to monitor trends in cancer incidence among HIV-infected individuals and to better understand the impact of earlier cART on NADM risk. The role of adjuvant anti-inflammatory or antithrombotic therapies to reduce cancer risk deserves further investigation.
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Emerging clinical issues related to management of multiorgan comorbidities and polypharmacy. Curr Opin HIV AIDS 2014; 9:371-8. [DOI: 10.1097/coh.0000000000000068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Saez-Cirion A, Jacquelin B, Barré-Sinoussi F, Müller-Trutwin M. Immune responses during spontaneous control of HIV and AIDS: what is the hope for a cure? Philos Trans R Soc Lond B Biol Sci 2014; 369:20130436. [PMID: 24821922 PMCID: PMC4024229 DOI: 10.1098/rstb.2013.0436] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
HIV research has made rapid progress and led to remarkable achievements in recent decades, the most important of which are combination antiretroviral therapies (cART). However, in the absence of a vaccine, the pandemic continues, and additional strategies are needed. The 'towards an HIV cure' initiative aims to eradicate HIV or at least bring about a lasting remission of infection during which the host can control viral replication in the absence of cART. Cases of spontaneous and treatment-induced control of infection offer substantial hope. Here, we describe the scientific knowledge that is lacking, and the priorities that have been established for research into a cure. We discuss in detail the immunological lessons that can be learned by studying natural human and animal models of protection and spontaneous control of viraemia or of disease progression. In particular, we describe the insights we have gained into the immune mechanisms of virus control, the impact of early virus-host interactions and why chronic inflammation, a hallmark of HIV infection, is an obstacle to a cure. Finally, we enumerate current interventions aimed towards improving the host immune response.
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Affiliation(s)
| | | | | | - M. Müller-Trutwin
- Institut Pasteur, Unité de Régulation des Infections Rétrovirales, Paris, France
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Abstract
The incidence of AIDS-defining cancers (ADCs) - Kaposi sarcoma, primary central nervous system lymphoma, non-Hodgkin lymphoma, and cervical cancer - although on the decline since shortly after the introduction of HAART, has continued to be greater even in treated HIV-infected persons than in the general population. Although the survival of newly infected people living with HIV/AIDS now rivals that of the general population, morbidity and mortality associated with non-AIDS-defining cancers (NADCs) such as lung, liver, anal, and melanoma are significant and also continue to rise. Increasing age (i.e. longevity) is the greatest risk factor for NADCs, but longevity alone is not sufficient to fully explain these trends in cancer epidemiology. In this review, we briefly review the epidemiology and etiology of cancers seen in HIV/AIDS, and in this context, discuss preclinical research and broad treatment considerations. Investigation of these considerations provides insight into why malignancies continue to be a major problem in the current era of HIV/AIDS care.
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McComsey GA, Kitch D, Sax PE, Tierney C, Jahed NC, Melbourne K, Ha B, Brown TT, Bloom A, Fedarko N, Daar ES. Associations of inflammatory markers with AIDS and non-AIDS clinical events after initiation of antiretroviral therapy: AIDS clinical trials group A5224s, a substudy of ACTG A5202. J Acquir Immune Defic Syndr 2014; 65:167-74. [PMID: 24121755 PMCID: PMC3943548 DOI: 10.1097/01.qai.0000437171.00504.41] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The association of inflammatory biomarkers with clinical events after antiretroviral therapy initiation is unclear. METHODS A5202 randomized 1857 treatment-naive subjects to abacavir/lamivudine or tenofovir-DF/emtricitabine with efavirenz or atazanavir/ritonavir. Substudy A5224s measured inflammatory biomarkers on subjects with available plasma from baseline and week 24 or 96. An exploratory analysis of the association of high-sensitivity C-reactive protein, interleukin-6 (IL-6), soluble receptors of tumor necrosis factor α (sTNF)-RI, sTNF-RII, TNF-α, soluble vascular cellular adhesion molecules (sVCAM-1), and soluble intercellular adhesion molecules (sICAM-1) with times to AIDS and to non-AIDS events used Cox proportional hazards models. RESULTS Analysis included 244 subjects; 85% men and 48% white non-Hispanic with median age 39 years, HIV-1 RNA of 4.6 log10 copies per milliliter, and CD4 of 240 cells per microliter. Overall, 13 AIDS events (9 opportunistic infections, 3 AIDS-cancers, and 1 recurrent bacterial pneumonia) and 18 non-AIDS events (6 diabetes, 4 cancers, 3 cardiovascular, and 5 pneumonias) occurred. Higher baseline IL-6, sTNF-RI, sTNF-RII, and sICAM-1 were significantly associated with increased risk of AIDS-defining events. Adjustment for baseline HIV-1 RNA did not change results, whereas adjusting for baseline CD4 count left only sTNF-RI and sICAM-1 significantly associated with increased risk. Time-updated values of IL-6, sTNFR-I and II, and sICAM-1 were also associated with an increased risk. For non-AIDS events, only higher baseline high-sensitivity C-reactive protein was significantly associated with increased risk, whereas higher IL-6 was marginally associated with higher risk. Analyses of time-updated biomarker values showed tumor necrosis factor α to be significantly associated with increased risk, even after adjustment for antiretroviral therapy, and CD4 count or HIV-1 RNA. CONCLUSIONS Higher levels of several inflammatory biomarkers were independently associated with increased risk of AIDS and non-AIDS events.
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Affiliation(s)
- Grace A McComsey
- Case Western Reserve University and Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | | | - Paul E Sax
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | - Anthony Bloom
- Frontier Science and Technology Research Foundation, Amherst, NY
| | | | - Eric S Daar
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
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