Metabolic Syndrome in People with HIV/AIDS

doi:10.4236/wja.2013.34037

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World Journal of AIDS, 2013, 3, 293-297

Published Online December 2013 (http://www.scirp.org/journal/wja)

http://dx.doi.org/10.4236/wja.2013.34037

Open Access WJA

293

Metabolic Syndrome in People with HIV/AIDS

Ana Paula Werberich1, Juliana Ceren1, Jayder Lucas Hotts Romancini2,

Giuliano Gomes de Assis Pimentel1, Miguel Spack Junior1, Áurea Regina Telles Pupulin3

1Department of Medicine, Universidade Estadual de Maringá, Maringá, Brazil; 2Department of Physical Education, Universidade

Estadual de Maringá, Maringá, Brazil; 3Department of Basic Health Sciences, Universidade Estadual de Maringá, Maringá, Brazil.

Email: [email protected]

Received July 16th, 2013; revised August 12th, 2013; accepted August 19th, 2013

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Highly Active Antiretroviral Therapy (HAART) has changed the clinical picture of HIV infection by

reducing morbidity and mortality rates in the population. However, alterations in lipid metabolism leading to hyper-

triglyceridemia, hypercholesterolemia, insulin resistance, hyperglycemia and redistribution of body fat, which are risk

factors for cardiovascular diseases, have emerged. Metabolic Syndrome (MS) is a complex disorder represented by a set

of cardiovascular risk factors commonly associated with central adiposity and insulin resistance. Aim: Current paper

evaluates the prevalence of MS in patients with HIV/AIDS using HAART from a reference Center in southern Brazil.

Methods: Samples comprised patients who had the infection for at least five years and were undergoing antiretroviral

therapy. Metabolic syndrome was identified according to the National Cholesterol Education Program Expert Panel on

Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP-ATPIII). A physical examination

was performed by evaluating percentage of body fat by bio-impedance and measuring blood pressure, determination of

Body Mass Index and Waist-Hip Ratio, glycaemia, total cholesterol, HDL cholesterol, LDL cholesterol and triglyc-

erides. Results: 184 patients were evaluated. MS prevalence was 30% (55 patients), with 30 (16.3%) males and 25

(13.7%) females. Conclusions: Brazil was among the first country profoundly impacted by the HIV/AIDS epidemic but

today, Brazil has less than 1% adult HIV prevalence, implemented treatment and prevention programs early in the epi-

demic. W her eas th er e is cu rren tly a sig nif ican t in crea se in th e survival of HIV patients by HAART, the patients reveal a

higher prevalence of Metabolic Syndrome in this specific population requiring political strategy of care to this popula-

tion.

Keywords: HIV/AIDS; Metabolic Syndrome; Metabolic Abnormalities; Brazil

1. Introduction

Brazil has currently 656,701 registered AIDS cases, with

38,776 new registered cases of HIV infection in 2012.

The above data rank second for reported cases for AIDS

in the Americas [1].

The Brazilian gov ernment’s policy to respon d to AIDS

with the universal, free su pply of antiretrovir al drugs and

medications for opportunistic diseases throug h the public

health system was heavily questioned, especially when

the policy was first implemented in the 1990s. The pro-

gram’s success is now acknowledged internationally, due

not only to this key component, but also to interaction

with other government ministries, in constant dialogue

with social movements and the scientific community.

Universal access to antiretroviral therapy has led to a

significant reduction in morbidity and mortality [2]. How-

ever, they have also widened changes in lipid metabolism

leading to hypertriglyceridemia, hypercholesterolemia

and other metabolic disorders, such as insulin resistance,

hyperglycemia and redistribution of body fat which are

risk factors in cardiovascular diseases [3]. These changes

are known as the lipodystrophy synd rome (HIVLS), offi-

cially described by the Food and Drug Administration

(FDA) in 1997, and also known as the syndrome of the

redistribution of body fat, or Metabolic Syndrome, asso-

ciated with an tiretrovir al therapy or, more recently, d ys li p i-

demic lipodystrophy associated with HIV/HAART [4-6].

Metabolic syndrome (MS) is a complex disorder rep-

resented by a set of cardiovascular risk factors commonly

associated with central adiposity and insulin resistance.

Metabolic Syndrome in People with HIV/AIDS

294

The importance of the epidemiological aspect, responsi-

ble for increased mortality cardiovascular estimated at

2.5 times, should be highlighted. Although MS still lacks

a well-established definition, there is a consensus indi-

cating that increased blood pressure, glucose metabolism

and lipid disorders and overweight are permanently asso-

ciated with increased cardiovascular morbidity and mor-

tality. The above has been observed in both developed

and developing countries. According to NCEP-ATP III,

MS represents the combination of at least three of the

following components, namely, abdominal obesity, tri-

glycerides > 150 mg/dL, low levels of HDL-cholesterol,

blood pressure > 130 mmHg, and fasting glucose > 110

mg/dL [7 ].

Few studies have been conducted in Brazil on MS in

patients with AIDS using HAART [8-11].

Current study evaluates the prevalence of metabolic

syndrome in HIV infected patients, from a two public

health Center for AIDS Care and Treatment in Parana,

southern Brazil.

2. Methodology

2.1. Study Setting and Design

One hundred and eighty-four patients with HIV/AIDS

were evaluated. The population under analysis consisted

of HIV/AIDS patients attended to at the 15th Regional

Health Unit in Maringa and at the 17th Regional Health

Unit in Londrina PR Brazil, covering 50 counties in the

north and northwestern region of the state of Paraná,

Brazil. The sample consisted of patients with at least a

five-year infection using antiretroviral therapy (HAART).

Patients were selected for the study after receiving the

required explanations on STD/AIDS at the nuclei of

Maringa and Londrina, and signed the consent form ap-

proved by the Committee for Ethics in Research involv-

ing Humans of the State University of Maringa. Survey

comprised a prevalence study with a convenience sample,

calculated by EpiInfo 5.5.1-2008 at a 90% confidence

level.

2.2. Participant Recruitment and Data Collection

Socioeconomic data were collected by a closed question-

naire comprising age, duration of infection, family in-

come, education, alcohol/illegal drugs, use of antiretro-

viral drugs, rate of CD4 + T cells and the occurrence of

opportunistic infections. The interviews were individual,

previou sly schedu led, with an av erage dur ation of tw enty

minutes.

Patients’ physical examination was subsequently per-

formed to determine fat percentage using a fat control

bio-impedance monitor Omron HBF 306 INT, and to de-

termine weight and height for Body Mass Index (BMI =

weight/height2). Height was measured by stadiometer

coupled to Welmy 200 with balance scale to the nearest

0.5 cm, with attached cursor for easy reading. Height de-

termination was performed by placing the patient bare-

foot on the base of the stadiometer, in an upright posture,

with feet together, arms pending down the body, touch-

ing the posterior surface of the body in scale measure-

ments.

Body weight was measured with leverage Welmy bal-

ance at 100 g precision. The patient was barefoot and

with as little clothing as possible. Patients were requested

to position themselves at the center of the scale platform

and remained upright, with arms down the body and

staring ahead so that no oscillations occurred at the time

of registration. The balance was checked before and after

weighing every ten patients.

The waist was measured in cm with an inelastic tape,

at midpoint between the iliac crest and the outer face of

the last rib. The hip was measured in centimeters with

inelastic tape at the iliac spine. Waist-hip ratio (WHR)

was obtained by the ratio between waist and hip circum-

ferences.

Standardized assessments of blood pressure were con-

ducted using a validated automatic device (OMRON CP-

705), and the average of eight measurements in two of-

fice visits was used to diagnose hypertension.

So that metabolic parameters could be evaluated,

blood samples were collected after a 12-hour fast. Dosa-

ges were performed for fasting glycaemia, triglycerides,

total cholesterol, HDL-cholesterol and LDL-cholesterol.

All biochemical measurements were performed with

specific commercial kits using enzymatic colorimetric

method according to the manufacturer’s specifications.

2.3. Data Analysis

Data entry analysis was done by Graph Pad Prism pro-

gram 5.00 for frequency analysis, followed by chi-square

test at p < 0.05 significance level.

3. Results

3.1. Demographic Characteristics of Population

One hundred and eighty-four patients were evaluated.

Gender distribution comprised 51.5% males and 48.5%

females. Females’ age ranged between 26 and 64 years

(mean 42 years) and males’ age ranged between 20 and

56 (mean 40 years).

Further, 73.8% received primary education, 23% sec-

ondary education and 3% never attended school. Lowest

schooling occurred in females. Whereas 74% of females

had only attended elementary school, lack of schooling in

males reached 34%.

All patients were using HAART for at least five years.

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295

3.2. Frequency of Metabolic Abnormalities of

Population

Biochemical changes in blood glucose occurred in 43 pa-

tients (23%), or rather, 16 (8%) females and 27 (15%)

males.

Table 1 shows abnormalities in lipid levels. Abnormal

HDL cholesterol occurred in 114 (61.9%) patients, featu-

ring high risk rates, with no difference between males

and females. Regarding levels of blood triglycerides, 57

(30.9%) patients had high levels with no difference be-

tween male and female percentage.

Abdominal obesity was reported in 42 (23%) patients,

with no significant difference between males and females.

Table 2 shows the results of classification according to

Heyward & Stolarczyk [1 2].

Blood pressure was high in 23 (12.5%) patients, or

rather, 14 ( 7.6%) ma les and 9 (5% ) f emale s.

Table 3 shows fat percentage according to classifica-

tion by Pollock & Wilmore [13] with regard to CD4+

level, 71.4% registered rates ab ove 200 cells/mm3, where

as 28.6% of patients had rates equal to or below the

above rate.

Table 4 shows the prevalence of metabolic syndrome

in 55 (30%) patients, or rather, 30 (16.3%) males and 25

(13.7%) females. Metabolic Syndrome represents the

combination of least three components listed.

4. Discussion

Current research reinforces the occurrence, evidenced by

several authors, of HAART impact on the metabo lism of

lipids and glucose. Dyslipidemia associated with HAA-

RT was characterized by elevated levels of LDL-chole-

sterol and by low levels of HDL cholesterol. The above

alterations have been associated with the development of

atherosclerosis and its co mplications, such as myocardial

infarction and peripheral v a scular di s eas e [14,15].

Current results corroborate studies on the undisputed

importance of HAART with its high patient survival, but

also on the concomitant emergence of the SLHIV-asso-

ciated Metabolic Syndrome and its cardiovascular meta-

bolic risks [3]. Another metabolic alteration has been

reported in HIV lipodystrophy syndrome (SLD), known

as fat redistribution syndrome, which causes an accumu-

lation of fat in the dorso-cervical (buffalo hump) and

abdominal region. Fat redistribution with abdominal li-

pohypertrophy predisposes the patient to cardiovascular

disease risk due to visceral fat, directly associated with a

higher incidence of changes in serum lipids and insulin

resistance, with a rise in risks for the development of

Type 2 diabetes [16]. This study is well established as

shown in Table 2, classification of cardiovascular risk in

these patients have a higher prevalence of medium and

high risk. Most patients had fat percentage of average to

poor (Table 3).

Kramer et al. [17] reported that HIV dyslipidemia in

the HAART therapy patient is characterized by high

LDL-cholesterol and reduced level of HDL-cholesterol.

The authors also suggested that the factors that led pa-

tients to have HIV dyslipidemia are still not clearly elu-

cidated. No one knows for sure whether it is directly

caused by HAART or whether it is the product of several

factors such as antiretroviral therapy, genetic predisposi-

tion, diet and exercise, or such factors as host response to

HIV infection.

Farhi et al. [18] conducted a stud y at a university hos-

pital in Rio de Janeiro, Brazil, with 268 HIV patients and

concluded that in male patients the prevalence of dyslip-

idemia was higher when compared to that of females,

and that family history of dyslipidemia was directly re-

lated to the occurrence of dyslipidemia and the time of

the use of HAART by patien t s.

Research by Smith et al. [19] in São Paulo, Brazil,

with 319 patients divided into HIV HAART users and

non-users showed that the concentrations of total choles-

terol, triglycerides and glucose were significantly higher

among patients taking HAART. These data imply a high

prevalence of metabolic abnormalities, particularly high

levels of cholesterol and triglycerides, in patients treated

with HAART drug therapy.

Almeida [20] observed significant increases in total

cholesterol, triglycerides and glucose in 110 patients af-

ter treatment with HAART. Glucose levels increased as a

result of HAART in this study even though gender,

smoking, intravenous drug use and age did not cause

significance levels of total cholesterol, triglyceride and

glucose levels during treatment.

Although the main focus of metabo lic changes in HIV

patients is attributed to the side effects of HAART, stud-

ies from the pre-HAART condition established that HIV

Table 1. Prevalence of hyperglycemia, hypercholesterolemia and hypertriglyceridemia in HIV patients using HAART. n =

184.

Patients HIV

n = 184 Glucose > 100 mg/dL CT > 200 mg/dL HDL < 50 mg/dL

or < 40 mg/dL LDL > 160 mg/dL TG > 150 mg/dL

n 43 47 114 82 57

% 23% 26% 61.9% 45% 30.9%

CT = Cholesterol Total, HDL = Cholesterol HDL, LDL = Cholesterol LDL, TG = Triglycerides.

Metabolic Syndrome in People with HIV/AIDS

296

Table 2. Cardiovascular risk classification according to the

relationship between waist and hips of HIV/AIDS patients.

n = 184.

Risk Classification n %

Low 32 17.4

Moderate 64 34.8

High 56 30.4

Towering 32 17.4

Classification of Heyward & Stolarczyk, 199 6.

Table 3. Classification of fat percentage in HIV/AIDS pa-

tients. n = 184.

Fat Percentage n %

Excellent 44 23.9

Well 13 7.1

Above media 44 23.9

Media 35 19

Bellow media 4 2.3

Bad 35 19.2

Very bad 9 4.6

Classification according to Pollock & Wilmore, 1993.

Table 4. Prevalence of metabolic syndrome in HIV/AIDS

patients. n = 184.

Metabolic Syndrome Parameters n %

Abdominal obes ity 52 28

Triglyceri de s > 15 0 mg/dL 57 30.9

HDL-cholesterol

< 50 mg/dL or < 40 mg/dL 114 61.9

Blood pressure > 130 mmHg 23 12.5

Glycaemia > 10 0 mg/dL 43 23

Metabolic syndr ome 55 30

infection itself would determine a more unfavorable lipid

profile with hypertriglyceridemia and low HDL-chole-

sterol. Constan et al. [21] included a prognostic implica-

tion of these changes, or rather, the lower the count of

CD4+, the greater are triglycerides levels and the lower

are HDL-cholesterol levels. The patho -physiology of this

association is not clear. There is still no consen sus on the

manner antiretroviral therapy enh ances this lipid disorder

and affects others associated with it, such as insulin re-

sistance, diabetes mellitus, central obesity and lipodys-

trophy. Our study showed that even with levels of CD4+

above 200 cells/mm3 found in a high alteration in levels

of triglycerides and HDL-cholesterol.

Current study shows that changes in blood levels of

HDL-cholesterol were high and corroborated the findings

of the above authors to explain these changes as a result

of the interaction HIV infection and antiretroviral ther-

apy.

Hsue et al. [22] retrospectively evaluated the risk fac-

tors and clinical outcome of 68 HIV patients hospitalized

between 1993 and 2003 for unstable angina or myocar-

dial infarction and compared the characteristics of this

population to a control group of 68 seronegative indi-

viduals with a diagnosis of acute coronary artery condi-

tion. The prevalence of smoking and low HDL-chole-

sterol was higher among HIV-positive patients, while in

the control group the prevalence for diabetes and dyslip-

idemia was higher. Although the rate of re-stenosis with

clinical manifestations was higher in patients with AIDS

and 29 angioplasties were performed in HIV-positive

patients, only 11 were performed in the control group. It

may be likewise inferred that low HDL-cholesterol may

be a significant cardiovascular risk factor in HIV pa-

tients.

Brazil and South Africa were among the first countries

profoundly impacted by the HIV/AIDS epidemic and had

similar rates of HIV infection in the early 1990s. Today,

Brazil has less than 1% adult HIV prevalence, imple-

mented treatment and prevention programs early in the

epidemic, and now has exemplary HIV/AIDS programs.

South Arica, by contrast, has HIV prevalence of 18% and

was, until recently, infamous for its delayed and inap-

propriate response to the HIV/AIDS epidemic. Although

Brazil has achieved so sui generis these indices mainly

due to free distribution of HAART may not be getting

adequately monitor these patients. Thirty years since the

first AIDS cases in Brazil few article related to appropri-

ate monitoring by health services and early identification

of patients with metabolic abnormalities inferring vul-

nerability increased.

5. Conclusion

In conclusion, the increasing number of antiretroviral

agents, longer duration of HAART use, and aging of the

HIV population, might contribute to the growing pre-

valence of metabolic syndrome and reduce the life ex-

pectancy of HIV-infected patients requiring political

strategy of care to this population in Brazil.

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