Changes in elevated cholesterol in the era of tenofovir in South Africa: risk factors, clinical management and outcomes.
Antiretroviral therapy (ART) has been associated with unfavourable lipid profile changes and increased risk of cardiovascular disease (CVD). With a growing population on ART in South Africa, there has been concern about the increase in noncommunicable diseases such as CVD. We determined risk factors associated with increased total cholesterol (TC) in a large cohort on ART and describe the clinical management thereof.



We conducted an observational cohort study of ART-naïve adults initiating standard first-line ART in a large urban clinic in Johannesburg, South Africa. TC was measured annually for most patients. A proportional hazards regression model was used to determine risk factors associated with incident high TC (≥ 6 mmol/L).



Significant risk factors included initial regimen non-tenofovir vs. tenofovir [hazard ratio (HR) 1.54; 95% confidence interval (CI) 1.14-2.08], age ≥40 vs. <30 years (HR 3.22; 95% CI 2.07-4.99), body mass index (BMI) ≥ 30 kg/m2(HR 1.65; 95% CI 1.18-2.31) and BMI 25-29.9 kg/m2(HR 1.70; 95% CI 1.30-2.23) vs. 18-24.9 kg/m2, and baseline CD4 count < 50 cells/μL (HR 1.55; 95% CI 1.10-2.20) and 50-99 cells/μL (HR 1.40; 95% CI 1.00-1.97) vs. > 200 cells/μL. Two-thirds of patients with high TC were given cholesterol-lowering drugs, after repeat TC measurements about 12 months apart, while 31.8% were likely to have received dietary counselling only.



Older age, higher BMI, lower CD4 count and a non-tenofovir regimen were risk factors for incident elevated TC. Current guidelines do not indicate regular cholesterol testing at ART clinic visits, which are the main exposure to regular clinical monitoring for most HIV-positive individuals. If regular cholesterol monitoring is conducted, improvements can be made to identify and treat patients sooner.
Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Jamieson
Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Evans
Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.|Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.|Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
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Brennan
Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Moyo
Right to Care, Johannesburg, South Africa.
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Spencer
Right to Care, Johannesburg, South Africa.
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Mahomed
Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Maskew
Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Long
Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.|Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
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Rosen
Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.|Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.|Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
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Fox
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019380:Anti-HIV Agents / Q000009:adverse effects* / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000009:adverse effects / Q000379:methods; D015331:Cohort Studies; D019468:Disease Management; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy*; D006801:Humans; D006937:Hypercholesterolemia / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology; D000068698:Tenofovir / Q000627:therapeutic use*; D016896:Treatment Outcome; D055815:Young Adult
D019380:Anti-HIV Agents; D000068698:Tenofovir
HIV; South Africa; antiretroviral therapy; cholesterol; clinical management