[HIV-infection, HAART (highly-active antiretroviral therapy) and hyperlipidemia].
METHODS
A 42-year-old man with long-standing HIV-infection (CDC C3) and multiple treatment failures was seen for follow-up 6 months after starting a new HAART (zidovudine, efavirenz, indinavir, ritonavir). The medical history is remarkable for a hypersensitivity reaction to abacavir, past smoking (10 pack years) and a family history of coronary heart disease of the patient's mother. Physical examination revealed discrete signs of lipoatrophy of the face, arms and legs, but no lipoaccumulation (hip-waist ratio 0.94; body mass index 22 kg/m2). Blood pressure measured 156/92 mmHg.


RESULTS
A rise in CD4 cell count from 24/ microL to 60/ microL was noted. For the first time, the HIV viral load decreased to < 50 copies/mL. Concentrations of triglycerides and cholesterol were found to be increased to 26 mmol/L (2275 mg/dL) and 15 mmol/L (580 mg/dL), respectively, compared previously normal readings. Other parameters were in the normal range.


METHODS
Continuation of HAART resulted in rising CD4 counts to > 200/ microL and HIV viral load suppression to < 50 copies/mL. Neither dietary measures nor treatment with pravastatin significantly changed the drug-induced mixed hyperlipidemia. Treatment with fenofibrate (200 mg qd), however, was followed by a significant reduction of triglyceride and cholesterol concentrations to 12 mmol/L (1050 mg/dL) and 10 mmol/L (387 mg/dL). Addition of pravastatin did not result in further improvement. Arterial hypertension was diagnosed by ambulatory 24-h blood pressure monitoring (systolic 157+/-11 mmHg; diastolic 97+/-10 mmHg).


CONCLUSIONS
HAART-induced mixed hyperlipidaemia is likely to increase the cardiovascular risk. According to first estimates, the 3-year risk of myocardial infarction amounts to 1.29 - 2.09 % for our patient. The 3-year risk of HIV progression to AIDS or death is > 30 % if HAART is stopped or fails upon switching due to unknown archived drug resistance. Thus, despite unsatisfactory lipid profiles, a modification of HAART seems only acceptable, if new, equally potent, but less lipidaemic drug combinations are available.
Abt. Infektiologie, Departement Innere Medizin, Universitätsspital Basel.
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Hirsch
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Battegay
D000328:Adult; D019380:Anti-HIV Agents / Q000009:adverse effects*; D023241:Antiretroviral Therapy, Highly Active / Q000009:adverse effects*; D018791:CD4 Lymphocyte Count; D002318:Cardiovascular Diseases / Q000209:etiology / Q000517:prevention & control; D002784:Cholesterol / Q000097:blood; D011345:Fenofibrate / Q000494:pharmacology / Q000627:therapeutic use*; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy*; D006801:Humans; D006949:Hyperlipidemias / Q000139:chemically induced*; D000960:Hypolipidemic Agents / Q000494:pharmacology / Q000627:therapeutic use*; D008297:Male; D016896:Treatment Outcome; D014280:Triglycerides / Q000097:blood; D019562:Viral Load
D019380:Anti-HIV Agents; D000960:Hypolipidemic Agents; D014280:Triglycerides; D002784:Cholesterol; D011345:Fenofibrate