Gynecomastia in HIV-positive adult men receiving efavirenz-based antiretroviral therapy at Newlands clinic, Harare, Zimbabwe

Background

Gynecomastia is known to occur in some men taking an efavirenz-based antiretroviral therapy (ART) regimen. However, the incidence and outcomes of gynecomastia are not known in Zimbabwe. We described the characteristics and outcomes of gynecomastia among male patients on an efavirenz-based ART regimen.

Methods

We conducted a retrospective cohort review of data of all male patients aged ≥18 years taking an efavirenz-based regimen at Newlands Clinic, Harare, Zimbabwe before 31 March 2017. The primary outcome was gynecomastia as defined by breast/nipple enlargement reported by patient and confirmed by clinical palpation. Routinely collected data on demographics, baseline CD4, body mass index, duration on efavirenz, clinical presentation and outcomes were extracted from the clinic database and analysed using STATA 12.1. We investigated for any associations with concomitant medicines using cox regression.

Results

We analysed data for 1432 men with a median age of 40 years (IQR: 33–48). Half of the patients were in WHO stage 1 at ART commencement. Median body mass index and CD4 count at efavirenz commencement was 21 (IQR: 19–23) and 260 cells/mm³ (IQR: 126–412) respectively. The incidence of gynecomastia was 22/1000 person-years (IQR: 17.3–27.8). Over half of the cases (58%) were bilateral and 75% of all cases developed within two years of starting efavirenz. There were no significant associations with concomitant use of isoniazid (HR: 0.95, p = 0.87) or amlodipine (HR: 0.43, p = 0.24). Gynecomastia resolved in 83.5% of cases following withdrawal of efavirenz with a median time to resolution of 3 months (IQR: 2–9).

Conclusion

The incidence of gynecomastia among patients taking efavirenz-based ART was low with most cases developing early on during treatment. Most cases resolved completely after withdrawing efavirenz.

Inflammatory Markers and Plasma Lipids in HIV Patients: A Correlation Analysis Study

Background

Recent evidence suggests that HIV infection, even with treatment, increases the risk of coronary heart disease (CHD) and that both chronic inflammation and traditional risk factors play key roles in HIV-associated CHD.

Subjects and Methods

Patients (N=152), attending Harare HIV clinic, 26% of them male and 82% of them on antiretroviral therapy (ART), were studied. Inflammatory markers comprising of cytokines such as pro-inflammatory tumor necrosis factor-α, (TNF-α), anti-inflammatory interleukin 10, (IL-10) and highly sensitive C reactive protein (hsCRP) together with lipids were assayed using enzyme linked immunosorbent assay (ELISA), immuno-turbidimetric and enzymatic assays, respectively. Correlation analysis of inflammatory markers versus lipid profiles was carried out using bivariate regression analysis.

Results

Anti-inflammatory cytokine IL-10 and inflammatory hsCRP levels were elevated when measured in all the HIV positive patients, while TNF-α and lipid levels were within normal ranges. Pro-inflammatory TNF-α was significantly higher in ART-naive patients than ART-experienced patients, whereas the reverse was observed for anti-inflammatory IL-10 and anti-atherogenic HDL-C. Correlation analysis indicated a significant positive linear association between IL-10 and total cholesterol (TC) levels but no other correlations were found.

Conclusion

High cytokine ratio (TNF-α/IL-10) indicates higher CHD risk in ART-naive patients compared to the ART-exposed. The CHD risk could be further strengthened by interplay between inflammatory markers and high prevalence of low HDL-C. Lack of correlation between pro-inflammatory markers (hsCRP and TNF-α) with lipid fractions and correlation between anti-inflammatory IL-10 with artherogenic TC were unexpected findings, necessitating further studies in future.

Use of Proviral DNA to Investigate Virus Resistance Mutations in HIV-infected Zimbabweans

Background:

Antiretroviral therapy (ART) to suppress HIV replication has reduced morbidity and mortality yet effectiveness of current HIV drugs is threatened by HIV drug resistance (HIVDR) mutations.

Objective:

To determine HIVDR mutations using proviral DNA from specimens of patients presenting to an HIV treatment clinic.

Methods:

DNA from 103 patients, 86 treatment-experienced, 17 treatment-naïve, were genotyped for the HIV-1C reverse transcriptase gene (RT; codons 21-304) using Sanger sequencing and sequences analyzed using Sequencher software. Resistance mutations were interpreted using Stanford HIVDR reference database.

Results:

Median age was 39 (IQR, 33-46) years and 80% of patients were female. Six-percent (n=6) had at least one HIVDR mutation, comprising NRTI-associated mutations, (M184V, T69D, T69N and V75I); NNRTI-associated mutations (G190A, K103N, V106M, Y181C) and thymidine analogue associated mutations (D67N, K70R, K219Q, L210W, M41L, T215Y). Of the six participants, with at least one HIVDR mutation, all were treatment experienced, five were on tenofovir, lamivudine and nevirapine and one was on tenofovir, lamivudine and atazanavir. There was no difference in median CD4 count and viral loads when patients were compared by presence of HIVDR mutations.

Conclusion:

We demonstrated the use of proviral DNA in HIVDR testing in adult patients and present that all the patients with various kinds of HIVDR mutations were treatment experienced, pointing to the role of drug regimens in driving viral mutations. Thus, the use of proviral DNA has potential to help provide surveillance on risk of HIVDR in HIV-infected individuals who are on treatment, which may assist in corrective treatment.

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

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