1. HIV and Fatigue Mariana Gerschenson, Ph.D.
Associate Professor of Medicine
Chair of the Cell and Molecular Biology Program
John A. Burns School of Medicine

2. Adults and children estimated to be living with HIV, 2007
Western &
Central Europe
[ – 1.0 million]
Eastern Europe & Central Asia
1.5 million
[1.1 – 1.9 million]
North America
1.2 million
[ – 2.0 million]
East Asia
[ – 1.1 million]
Middle East & North Africa
[ – ]
Caribbean
[ – ]
South & South-East Asia
4.2 million
[3.5 – 5.3 million]
Sub-Saharan Africa
22.0 million
[20.5 – 23.6 million]
Latin America
1.7 million
[1.5 – 2.1 million]
Oceania
74 000
[ – ]
Total: 33 million (30 – 36 million)

3. Background on Fatigue and HIV
HIV+ have prevalence rates of fatigue of up to 98%
Fatigue affects the ability to work, interactions with family & friends, unable to manage finances, and needing an entire day for a simple household task
Fatigue intensity is higher: duration of HIV, in women, older than age 35, Hispanics, disabled subjects, low income, lack of health insurance, and IV drug use
Harmon, J.L. et al, J Assoc Nurses AIDS Care. 2008;19(2):90-7.

4. HIV Fatigue Tools
HIV-Related Fatigue Scale (HRFS)1-Similar to Likert-type 56-item self-report measurements: fatigue intensity and impact of fatigue on daily function, description of fatigue, and triggers of fatigue
Sign and Symptom Checklist HIV (SSC-HIVrev)2
This self-report tool on HIV-related signs and symptoms measures the presence and intensity of 72 symptoms, with 1 = mild, 2 = moderate, and 3 = severe.
1. Barrosso J. and Lynn, M.R., Journal of the Association of Nurses in AIDS Care, 13: (2002)
2. Holzemer et al., Journal of the Association of Nurses in AIDS Care 12 (5), pp (2001)

5. HIV Fatigue Etiology
Active infection and co-infections with Hep C or OI. Fatigue is not associated with CD4 levels or viral load
Anemia
Hormonal Imbalances: low testosterone
Psychological factors: depression, anxiety
Poor nutrition: low Vitamin B12
Sleep and Activity: Efavirenz [Sustiva] can cause nightmares or unusual dreams.
Medication Side Effects

6. Emerging New Landscape of HIV Complications:
New factors in the HAART era
Potent/Toxic antiretrovirals
Alcohol
Aging
Genetics
Chronic “smoldering” immune
activation
Mitochondrial toxicity
HOST
HIV
EVOLVING CHRONIC COMPLICATIONS
Altered Phenotypes-Mitochondrial
Fatigue
Wasting/Myopathy
Lipodystrophy
Increased Diabetes/CV Risk
Dementia, Peripheral Neuropathy
Hepatic-Fatty Liver

7. Lipoatrophy in 2008
Understanding the mechanism of HIV lipoatrophy continues to be a relevant issue even in the U.S. (where d4T and even ZDV is being utilized less and less) as a recent study utilizing Tenofovir as part of 1st time antiretroviral therapy (A5142) showed that up to 12% of such individuals had limb fat loss of >20% on study*
ZDV or d4T are being used in Asia and Africa
*Haubrich RH, et al. Metabolic Outcomes of ACTG 5142: A Prospective, Randomized, Phase III
Trial of NRTI-, PI-, and NNRTI-sparing Regimens for Initial Treatment of HIV-1 Infection.
14th Conference on Retrovirus and Opportunistic Infections. LA, CA 2007.

8. Postulated Mechanisms for Body-Fat Abnormatilites by Drug Class
NRTIs
mtDNA polymerase-g inhibition and mtRNA depletion both lead to
Impaired oxidative phosphorylation
Altered ATP levels
Cell apoptosis
Peripheral subcutaneous lipoatrophy with/without visceral fat accumulation → altered WHR
PIs (unboosted “older” therapies: IDV, SQV, RTV, APV)
Inhibition of Glut4 (by IDV)
Insulin resistance
Inhibition of transcription factors, eg. PPAR-g, SREBP-1 (by RTV)
Cellular apoptosis
LPL, ME, and FAS inhibition (by SQV and RTV)
Decreased adipocyte differentiation
NNRTIs
Efavirenz has been shown to suppress lipogenic pathways of adipocytes in vitro
PBMC depletion does not correspond with HIV LA (most people do not use this as a marker, usually because there is platelet contamination, which has no nuclei and this alters the numbers)
There is a myopathy – original work by Eric Shonn, or Bill Lewis
Edward McKees has been working on phosphorylation in mice (ZDV inhibits thymidine phosphorylation in rat heart or liver)
We also know that PIs can effect protolytic mitochondrial processes in yeast
David Nolan (and here Mallon- slide 15) showed an increase of uncoupling RNA message in pts treated with NRTIs
Domingo P et al. AIDS (16): Subcutaneous adipocyte apoptosis occurs in lipoatrophic areas of patients with HIV-1 protease inhibitor- associated lipodystrophy
Carr A, et al. AIDS. 2000;14:F25-32; McComsey GA, et al. AIDS. 2005;19:15–23; Domingo P, et al. AIDS. 1999;13:2261–67; Mynarcik D, et al. J AIDS. 2005;38:53–56; Walker UA, et al. J AIDS. 2002;29:117–21; Roche R, et al. AIDS. 2002;16;13–20; Vernochet C, et al. AIDS. 2003;17:2177–80. Domingo P, et al. AIDS (16):

9. Development of Metabolic Disease in HIV Patients
Lipodystrophy
Visceral Adiposity
Fat depletion
Elevated plasma
FFA
Increased
Intramyocellular/
Intrahepatic Fat
INSULIN RESISTANCE
Genetic Predisposition
Impaired Mitochondrial
Activity
Direct PI Effect
GLUT4
Insulin-resistance-mediated
failure to suppress lipolysis
NRTI-mediated
Mitochondrial toxicity
in muscle
Hepatic steatosis
Chronic Inflammatory
Changes induced by HIV
Cytokine dysregulation
Age-related increase
In Insulin Resistance
Shikuma, CM, Day L, Gerschenson, M. Current Drug Targets-Infectious Disorders,

10. Mitochondria and Macrophages in HIV Lipoatrophy Model
BLOOD
Monocytes
HIV virus
HIV-infected and non-infected, activated monocytes
secreting cytokines
NRTIs
Infiltrating activated macrophages
FAT
Mitochondrial and cellular dysfunction induced by NRTIs
Pre-adipocytes and adipocytes
Macrophage-induced amplification of inflammation and cellular damage 1 2 3 4

11. Mitochondrial DNA Polymerase-γ Hypothesis
The mitochondrial DNA polymerase-γ is the principal polymerase required for mitochondrial DNA replication
Susceptible to inhibition by NRTIs
Inhibition can lead to mtDNA depletion
NRTI
Phosphorylation
NRTI-TP
DNA Pol-g
mtDNA Abundance
mtDNA
mtDNA Oxidation
Antioxidant Defenses
OXPHOS
The mitochondrial DNA polymerase gamma is the principal polymerase required for mitochondrial DNA replication
Susceptible to inhibition by NRTIs
Inhibition can lead to mtDNA depletion
“Mitochondrial DNA polymerase- appears much more susceptible to inhibition by nucleoside and nucleotide analogue antiretrovirals.”1
“The DNA pol-gamma hypothesis states that inhibition of mtDNA replication by NRTIs leads to mitochondrial dysfunction. This is accomplished via mtDNA depletion and structural alterations to the mitochondrial genome, which encodes many of the components necessary for aerobic metabolism through oxidative phosphorylation (OXPHOS).”2
1. Kakuda TN. Clin Ther. 2000; 22:685–708.
2. Day L et al. Mitochondrion. 2004; 4:95–109.
Energetics
ROS
Cell Dysfunction
Velsor LW. Toxicol Appl Pharmacol. 2004;99:10-19.

12. Hypothesis: Potential Consequences of Mitochondrial Dysfunction
ART
HIV
HIV
Cytokines
Metabolic Disease
(LD, IR,  TGs)
DNA polymerase-g
Uncoupling
Transport
Oxidative Stress
Apoptosis
Phosphorylation
Proteolytic Processing
Glycosylation
Lipodystrophy
Increased lactate correlates with impaired mitochondrial function1,2
Mitochondrial derived lipid oxidative markers (ROS) are significantly increased in lipoatrophy3
IR can be cause by LD, or Hepatic steatosis
The measurement of lactate, which is increased in NRTIs patients, is the hallmark of mitochondrial complications.
“Long-term complications of ART are increasingly recognized as significant causes of morbidity and mortality. Many of these complications are thought to be mediated through mitochondrial injury, which appears to be the result of nucleoside analogue toxicity…. A syndrome of fatty liver (steatosis) with lactic acidosis represents the most fulminant presentation of such antiretroviral toxicity… However, lactate elevations are not a component of NAFLD, suggesting other factors must also be involved.” 1
“Hyperlactatemia and lactic acidosis have been observed in HIV-infected patients receiving antiretroviral therapy. The spectrum of disease ranges from mild to moderate asymptomatic (or sub-clinical) hyperlactatemia to fulminate and life threatening lactic acidosis. Evidence suggests that exposure to one or more NRTIs plays a central role through toxic effects on mitochondrial function… In addition to inhibiting HIV reverse transcriptase, NRTIs inhibit mitochondrial DNA polymerase γ, an essential enzyme in the replication process of mtDNA. Inhibition of this enzyme depletes mtDNA and impairs mitochondrial function. In vitro studies using NRTI-exposed human T-lymphoblastoid cell lines have demonstrated a rapid toxic effect on drug- exposed cells, leading to depletion of mtDNA, morphologic changes in mitochondria, and increased production of lactic acid. These effects appear to be dose dependent.“2
1. Day L, et al. Mitochondrion. 2004;4:95–109.
2. AACTG Metabolic Guides:
3. McComsey GA, Morrow JD. J Acquir Immune Defic Syndr. 2003;34:45-9.
Neuropathies
Hepatic Steatosis
Myopathy
Pancreatitis
Lactic Acidosis
Day L, et al. Mitochondrion. 2004;4:95–109. AACTG Metabolic Guides: McComsey GA, Morrow JD. J Acquir Immune Defic Syndr. 2003;34: Dagan T, Sable C, Bray J, Gerschenson M. Mitochondrion. 2002;1: Gerschenson, M. and Brinkman, K. Mitochondrion. 2004;4(5-6):

13. Talk Summary Fatigue is common in HIV+ patients
Fatigue is associated with HIV complications e.g. lipoatrophy
HIV lipoatrophy has a mitochondrial etiology; mtDNA, mtRNA, OXPHOS, and ATP levels are altered in subcutaneous fat.
Mitochondrial OXPHOS in PBMCs correlates with subcutaneous fat OXPHOS

14. HIV as a Model for Fatigue
Metabolic syndrome: hypertension, hyperlipidemia, and insulin resistance
Increase in cytokines: TNF-, IL-6, MCP-1, IL-1
Human tissue or cell specific studies to understand pathogenesis
Minimally invasive systemic biomarker(s) to correlate with prevention, diagnosis, and progression

15. References for HIV and Fatigue
Harmon, J.L. et al, Demographic and illness-related variables associated with HIV-related fatigue, J Assoc Nurses AIDS Care. 2008;19(2):90-7.
Shikuma, CM, Day L, Gerschenson, M. Insulin resistance in the HIV-infected population: the potential role of mitochondrial dysfunction.Current Drug Targets-Infectious Disorders,
Gerschenson M, Brinkman K., Mitochondrial dysfunction in AIDS and its treatment. Mitochondrion Sep;4(5-6): Epub 2004 Sep 25.
Highleyman,L. A Comprehensive Look at HIV-Related Fatigue,, 2001,