Jul Gerrior

Recombinant human growth hormone improves the fat redistribution syndrome (lipodystrophy) in patients with HIV.

OBJECTIVE To determine the efficacy of recombinant human growth hormone (rhGH) in the treatment of the fat redistribution syndrome (FRS) in patients with HIV. DESIGN A prospective, open-label study. SETTING An urban, university-affiliated Infectious Disease Clinic. PATIENTS Ten HIV-infected patients (seven men, three women) with FRS. INTERVENTIONS Treatment with 6 mg of rhGH a day, subcutaneously for 12 weeks. MAIN OUTCOME MEASURES Body mass index (BMI), body composition by bioelectrical impedance analysis (BIA), body composition by anthropometrics (including waist/hip ratio), buffalo hump. RESULTS The mean age was 41.7 years, the CD4 cell count was 247, and the HIV RNA was 95 735 copies/ml; 50% had undetectable viral RNA. The BMI was significantly increased from baseline to the end of treatment with growth hormone (25.3-26.9 kg/m2; P < 0.04); the waist/hip ratio significantly decreased from baseline levels, after treatment with growth hormone (1.03-0.9; P < 0.04); mid-thigh circumference increased significantly when baseline was compared with measures after treatment (49.1-51.8 cm; P < 0.03). One patient had to discontinue therapy because of hyperglycemia. CONCLUSION Short-term treatment with rhGH improved the alterations in body shape that occur with FRS in HIV-infected patients. Waist/hip ratios and mid-thigh circumference are useful measures to follow alterations in body shape in FRS.

Risk of Cardiovascular Disease in a Cohort of HIV-Infected Adults: A Study Using Carotid Intima-Media Thickness and Coronary Artery Calcium Score

BACKGROUND There is concern that human immunodeficiency virus (HIV) infection and the use of highly active antiretroviral therapy lead to accelerated atherosclerosis and increased risk of cardiovascular disease. We measured 2 surrogate markers of subclinical atherosclerosis, carotid intima-media thickness (c-IMT) and coronary artery calcium (CAC) scores, in HIV-infected adults. METHODS A cross-sectional analysis of 242 men and 85 women with HIV infection was used. Carotid ultrasonography and coronary computed tomography were performed, and their associations with cardiovascular risk factors were examined. RESULTS Among men, the mean (+/- standard deviation [SD]) common c-IMT was 0.62+/-0.2 mm, the mean (+/-SD) internal c-IMT was 0.76+/-0.5 mm, and 136 patients (56.1%) had detectable CAC. Among women, the mean (+/-SD) common c-IMT was 0.59+/-0.2 mm, the mean (+/-SD) internal c-IMT was 0.66+/-0.4 mm, and 40 patients (47.1%) had detectable CAC. Neither the c-IMT nor the CAC score differed by antiretroviral therapy class or individual medications for either sex. For men, age and waist circumference independently predicted common c-IMT; age, systolic blood pressure, and high-sensitivity C-reactive protein level independently predicted internal c-IMT; and age, apolipoprotein B level, and high-sensitivity C-reactive protein level independently predicted CAC score. For women, age and body mass index independently predicted common c-IMT; age independently predicted internal c-IMT; and age and glucose level independently predicted CAC score. CONCLUSIONS Our participants had more abnormal surrogate markers than expected at a relatively young age, but those were not associated with use of highly active antiretroviral therapy or protease inhibitors. At present, the positive associations were primarily with traditional and novel cardiovascular risk factors. Some HIV-specific (not treatment-specific) factors were observed; they may become more evident with prolonged HIV infection and treatment.

Metabolic Syndrome and Subclinical Atherosclerosis in Patients Infected with HIV

BACKGROUND The present study examines the association between carotid and coronary atherosclerosis and metabolic syndrome in human immunodeficiency virus (HIV)-infected adults. METHODS We measured the common and internal carotid intima-media thickness (c-IMT) using B-mode ultrasonography, and we measured coronary artery calcium (CAC) using high-resolution, electrocardiographic, synchronized, computed tomography, for 314 HIV-infected men and women. Metabolic syndrome was defined by National Cholesterol Education Program/Adult Treatment Panel III criteria. We compared the c-IMT measurements and CAC scores of patients with metabolic syndrome with the scores of those without metabolic syndrome using a Wilcoxon test for continuous variables and a chi2 test for categorical variables. To examine the association between surrogate markers and metabolic syndrome, we used logistic regression analysis. RESULTS Participants with metabolic syndrome were more likely to have a common c-IMT measurement >0.8 mm than were those without metabolic syndrome (17% vs.7%; P=.009), but both groups were equally likely to have an internal c-IMT measurement >1.0 mm (20% vs. 13%; P=.15). Any positive CAC score was more likely to occur for participants with metabolic syndrome (80.3% vs. 46.7%; P<.0001). In a multivariate model adjusted for sex, age, ethnicity, and smoking status, participants with metabolic syndrome were more likely than those without metabolic syndrome to have an abnormal common c-IMT measurement (odds ratio [OR], 2.9; P=.020) and detectable CAC scores (OR, 4.9; P<.0001) but not a higher internal c-IMT measurement (OR, 1.6; P=.255). CONCLUSION Our study demonstrates that HIV-infected individuals with metabolic syndrome may be at increased risk for subclinical atherosclerosis and supports screening for metabolic syndrome among HIV-infected patients at risk for cardiovascular disease.

Successful Treatment of Diarrheal Disease Associated with Enteroaggregative Escherichia coli in Adults Infected with Human Immunodeficiency Virus

The presence of enteroaggregative Escherichia coli (EAggEC) in stool has been strongly associated with persistent diarrhea. No treatment trials have been done to demonstrate that clearance of EAggEc results in an improvement of diarrheal symptoms. Twenty-four adults infected with the human immunodeficiency virus (HIV) with diarrhea and EAggEC were randomized to a double-blind placebo-control cross-over treatment trial (ciprofloxacin 500 mg orally twice daily for 7 days vs. placebo). After treatment with ciprofloxacin, the subjects had significantly fewer (50%) stools per day (from 5.0+/-2. 9 to 2.4+/-1.9). Intestinal symptoms decreased by 42% after active treatment. EAggEc were eradicated from stool of all participants after active treatment. These data strengthen the link between the presence of the EAggEc in stool and their role in the pathogenesis of diarrheal disease. It is likely that EAggEc are a treatable cause of diarrheal disease in some persons with HIV and no other apparent enteric pathogen.

Markers of Atherosclerosis and Inflammation and Mortality in Patients with HIV Infection

OBJECTIVE HIV-infected patients are at increased risk for cardiovascular disease, which may be mediated in part by inflammation. Surrogate marker studies suggest an increased prevalence of vascular abnormalities in HIV infection. We examined the association of all-cause mortality in HIV-infected patients with carotid artery intima-media thickness (cIMT) and high-sensitivity C-reactive protein (hsCRP). DESIGN AND METHODS Baseline risk factors, cIMT and hsCRP were prospectively measured in 327 HIV-infected participants. Follow-up time with median of 3.1 years was calculated from baseline to death or censored dated 7/31/07. Cox Proportional Hazards models were used to study risk factors associated with mortality. RESULTS Thirty-eight (11.6%) of participants have died since study enrollment. cIMT was significantly higher in those who died and decedents were significantly more likely to have cIMT above the 75th percentile. Those who died had higher hsCRP than those alive and more had hsCRP values above 3mg/L. CD4 count was lower and log(10) viral load was higher in decedents, but antiretroviral regimens were similar in both groups. cIMT and hsCRP levels were significantly associated with mortality (HR = 2.74, 95% CI 1.26-5.97, p = 0.01; HR = 2.38, 95% CI 1.15-4.9, p = 0.02). CONCLUSIONS Our study demonstrated a strong association of carotid IMT and hsCRP with all-cause death in this HIV-infected population despite being similar with respect to exposure to antiretroviral medications. Together these surrogate markers may be indices of chronic inflammation and unfavorable outcomes in HIV-positive patients.

Micronutrients : current issues for HIV care providers

Malnutrition often accompanied by low serum levels of micronutrients was common in HIV-infection prior to the introduction of highly active antiretroviral therapy (HAART) and is still common in much of the world that has limited access to antiretroviral therapy (ART). Chronic diarrhea anorexia malabsorption impaired nutrient storage increased energy demands and altered metabolism were the primary contributors to these nutritional deficiencies. Today macronutrient deficiencies are less common and less severe in HIV-infected populations living in resource-sufficient countries. However following the introduction of HAART new questions about the importance of micronutrients in HIV infection are emerging. (excerpt)

Pilot randomized trial of nutritional supplementation in patients with tuberculosis and HIV–tuberculosis coinfection receiving directly observed short‐course chemotherapy for tuberculosis

Objective  To investigate the effects of nutritional supplementation on the outcome and nutritional status of south Indian patients with tuberculosis (TB) with and without human immunodeficiency virus (HIV) coinfection on anti‐tuberculous therapy.

Comparing Megestrol Acetate Therapy with Oxandrolone Therapy for HIV-Related Weight Loss: Similar Results in 2 Months

Weight loss is known to impact survival among patients infected with human immunodeficiency virus (HIV) even in the era of highly active antiretroviral therapy (HAART). In a randomized trial, we compared the effects of 2 months of treatment with either megestrol acetate (800 mg every day) or oxandrolone (10 mg twice per day) on body weight and composition in patients with weight loss of > or =5 kg who were receiving HAART. The mean weight was 66 kg, and the mean body mass index was 21. Mean weight gain in the megestrol acetate and the oxandrolone arms were 2.8 kg (4.6% of the baseline value) and 2.5 kg (3.9% of the baseline value), respectively (P=.80). Lean body mass accounted for 39% of weight gain in the megestrol acetate arm and 56% in the oxandrolone arm (P=.38). Seven patients in the megestrol acetate arm and 5 patients in the oxandrolone arm reported minor adverse events (P=.74). In conclusion, megestrol acetate therapy and oxandrolone therapy have similar effects on body weight and composition and are safe and well-tolerated during HAART.

The Fat Redistribution Syndrome in Patients Infected with HIV: Measurements of Body Shape Abnormalities

OBJECTIVE To describe the body shape changes in the syndrome of fat redistribution or lipodystrophy seen in patients infected with HIV. DESIGN An objective description of patients with HIV with fat redistribution syndrome. Body-height, weight, shape, and composition were measured by anthropometrics and biolectrical impedance analysis by a single observer. Clinical data were collected by chart review. SUBJECTS/SETTING Thirty-nine patients with HIV receiving primary HIV care at a university hospital-affiliated infectious disease clinic who presented with complaints of body shape changes or who were referred by their primary care providers for body shape changes. ANALYSIS Descriptive statistics were performed. RESULTS Four of the 39 patients (10%) had not used protease inhibitor therapy. HIV status (by clinical presentation, CD4 and VL) varied widely. Laboratory abnormalities were moderate. Percent body fat differed widely when measured by bioelectrical impedance analysis and anthropometry (23% vs 13%). The mean body mass index was 25.6 kg/m2 for men and 25.8 kg/m2 for women. The mean waist/hip ratio was above normal, at 1.02. The mean mid-arm circumference and triceps skinfolds were below national standards for both men (30.4 cm and 8.1 mm, respectively) and women (26.7 cm and 7.5 mm, respectively). Nine patients (23%) had an increased dorso-cervical pad. Seventeen patients returned for follow-up measurements at 3 months; no significant differences were found between baseline and follow-up measurements. CONCLUSIONS The waist/hip ratio, mid-arm and mid-thigh circumference, and triceps skinfolds were useful measures to define and follow the fat redistribution syndrome in patients with HIV. These body composition changes were not transitory in this short follow-up period.

Alterations in lipid profiles in HIV-infected patients treated with protease inhibitor therapy are not influenced by diet.

BACKGROUND The use of protease inhibitor (PI) -based highly active antiretroviral therapy (HAART) in patients infected with human immunodeficiency virus (HIV) has been linked to alterations in lipid profiles. METHODS Longitudinal cohort study. Lipid profiles were evaluated pre- and post-PI therapy in 49 HIV-infected patients. Diet was also evaluated to determine any contribution to alterations in lipid levels. RESULTS Pre- and post-PI-based HAART samples were examined from 42 men and 7 women, mean age 40.6 years. Mean CD4 count pre-PI was 242 +/- 205 cells/mm(3); HIV RNA was 4.2 log(10) copies/mL; body mass index (BMI) was 24.7 +/- 3.6 kg/m(2); body fat was 17.1 +/- 9.1 kg by bioelectrical impedance analysis (BIA), dietary intake was 2654 +/- 732 kcal/day. Post-PI samples were collected 5.7 +/- 1.66 months after starting therapy. CD4 counts increased to 384 +/- 323 cells/mm(3) and RNA decreased 1 log post-PI. Post-PI BMI (25.2 kg/m2), percent body fat (17.4%) and caloric intake (2656 kcal/day) were unchanged. Pre-PI total cholesterol (TC) in men was 167.6 +/- 42.4 mg/dL; TC increased (190.4 +/- 47.9 mg/dL) post-PI (p < .0001). Pre-PI triglycerides (TG) were 154.5 +/- 109.4 mg/dL; TG increased post-PI (266.1 +/- 363.6 mg/dL, p < .03). Low-density lipoprotein (LDL) -C was 97.8 +/- 31 mg/dL pre-PI and rose to 107.1 +/- 34.7 mg/dL post-PI (p < .05). High density lipoproteins (HDLs) were below desired levels before initiation of PI therapy and remained low. CONCLUSIONS PI therapy significantly alters lipid profiles in HIV-infected patients. Dietary intake did not contribute to changes in lipid profile. More longitudinal studies are needed to demonstrate whether these alterations contribute to additional cardiovascular risk.